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CENTER "OP MEALTI^ ECONOMICS RESEARCH 



30C Pifth Avenue 6tn Pioc- 
•.Vs:t,ham, MA 02" =^4 



ACCESS TO PHYSICIANS' SERVICES FOR 

VUNERABLE BENEFICIARIES: 

IMPACT OF THE MEDICARE FEE SCHEDULE 



FINAL REPORT 



Prepared by: 

Janet B. Mitchell, Ph.D. 
Susan G. Haber, Sc.D. 



with: 

Center for Health Economics Research 

300 Fifth Avenue, 6* Floor 

Waltham, Massachusetts 02154 



November 26, 1996 



T[\e research presented in this report was perfonned under Health Care Financing Administration (HCFA) Cooperative Agreement No. 17-C-90037/1- 
02. The opinions expressed are those of the authors and do not necessarily reflect the positions of HCFA or Center for Healtli Economics Research. 



TABLE Of CONTENTS 

PAGE 

3.2 Descriptive Results 3-2 

3.2.1 Price Changes 3-2 

3.2.2 Outpatient Visits 3-4 

3.2.3 Emergency Room Visits and Ambulatory Care Sensitive Admissiors...3-5 

3.2.4 Mammography and Pap Tests 3-6 

3.2.5 Cataract Surgery 3-7 

3.2.6 Financial Liability 3-8 

3.3 Regression Results 3-9 

3.3.1 Specification and Estimation 3-9 

3.3.2 MPS Impacts 3-12 

3.3.3 Differential Use by Vulnerable Patient Groups 3-15 

3.3.4 Time Trends 3-17 

4.0 EPISODES OF CARE ANLAYSIS 4-1 

4.1 Introduction 4-1 

4.2 Descriptive Results 4-2 

4.2.1 Time Trends in Treatment Patterns for AMI Patients 4-2 

4.2.2 Time Trends in Treatment Patterns for TIA Patients 4-4 

4.2.3 Changes in Payment Rates for Episode Services 4-6 

4.3 Regression Results 4-7 

4.3.1 Specification and Estimation 4-7 

4.3.2 Results for AMI Patients 4-9 

4.3.3 Results for TIA Patients 4-11 

4.3.4 The Role of Specialty in Explaining Access to Tests and Procedures.... 4-13 

REFERENCES 

APPENDIX A - ACCESS VARIABLE DEHNmONS 

APPENDIX B - PRICE VARIABLE DEHNITIONS 

APPENDIX C - DETAILED DESCRIPTFVE TABLES FOR NATIONAL SAMPLE 



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TABLE 2-1 
TABLE 2-2 
TABLE 2-3 
TABLE 3-1 
TABLE 3-2 

TABLE 3-3 

TABLE 3-4 

TABLE 3-5 

TABLE 3-6 

TABLE 3-7 

TABLE 3-8 

TABLE 3-9 
TABLE 3-10 
TABLE 3-11 

TABLE 3-12 
TABLE 3-13 

TABLE 3-14 



TABLE OF TABLES 

PAGE 

Unweighted Sample Sizes, 1991 7.4 

Weighted Proftle of Nahonal Sample, 1991 2-5 

Average Annual Unweighted Sample Sizes for Episode of Care Analysis 2-8 

Changes in Medicare Fees and Relative Private-Medicare Fees 3-19 

Average Number of Oupatient Visits Stratified by Actual MFS Payment Change 

and Vulnerable Population Group, 1991-1993 3-20 

Average Number of Emergency Room Visits Stratified by Actual MFS Payment 
Change and Vulnerable Population Group, 1991-1993 3-21 

Average Number of Ambulatory Care Sensihve (ACS) Admission Rates Sh-atified 

by Achial MFS Payment Change and Vulnerable Population Group, 1991-1993 3-22 

Percent of Femaile Beneficiaries Receiving Mammography Stratified by Actual 

MFS Payment Change and Vulnerable Population Group, 1991-1993 3-23 

Percent of Female Beneficiaries Receiving Pap Tests Sh-atified by Actual MFS 
Payment Change and Vulnerable Population Group, 1991-1993 3-24 

Cataract Surgeries Stratified by Actual MFS Payment Change and Vulnerable 
Populahon Group, 1991-1993 3.25 

Average Annual Part B Coinsurance Liability by Vulnerable Population 

Groups, 1991-1993 3.26 

Average Annual Extra Liability by Vulnerable Populations Group, 1991-1993 3-27 

Assignment Rate by Vulnerable Population Groups, 1991-1993 3-28 

Means of Dependent and Independent Variables in Regressions for 

National Sample 3.29 

Means of Dependent and Independent Variables in Regressions for Female 
Beneficiaries in National Sample 3.3O 

Regression Results: MFS Impacts on the Probability of an Outpatient Visit, 

Number of Outpatient Visits, Probability of an Emergency Room Visit, 

and Probability of an ACS Admission 3.3I 

Regression Results: MFS Impact on the Probability of Cataract Surgery 3-32 



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TABLE OF TABLES 

PAGE 

TABLE 3-15 Regression Results: MFS Impact on the Probability of an Outpatient Visit, 
Number of Outpatient Visits, Probability of a Pap Test, and Probability 
of Mamniography for Women 3-33 

TABLE 3-16 Regression Results: MFS Impact on the Probability of Mammography for 

Women (Mammography Price) 3-34 

TABLE 3-17 Regression Results: Time Trends for th" Probability of an Outpatient Visit, 
Number of Outpatient Visits, Probability of an Emergency Room Visit, and 
Probability of an ACS Admission 3-35 

TABLE 3-18 Regression Results: Time Trends for the Probability of Cataract Surgery 3-36 

TABLE 3-19 Regression Results: Time Trends for the Probability of an Outpatient Visit, 
Number of Outpatient Visits, Probability of a Pap Test, and Probability of 
Mammography for Women 3-37 

TABLE 3-20 Regression Results: Time Trends for the Probability of Mammography for 

Women (Mammography Price) 3-38 

TABLE 4-1 Treatment Patterns for Black and White Patients with AMI: 1991-1993 4-14 

TABLE 4-2 Treatment Patterns for Medicaid-Eligible and Non-Eligible Patients with 

AML 1991-1993 4-15 

TABLE 4-3 Treatment Patterns for Urban Poor and Non-Poor Patients with AMI: 1991-1993 ....4-16 

TABLE 4-4 Treatment Patterns for Rural Poor and Non-Poor Patients with AMI: 1991-1993 4-17 

TABLE 4-5 Treatment Patterns for Urban Shortage Area and Non-Shortage Area Patients 

with AMI: 1991-1993 4-18 

TABLE 4-6 Treatment Patterns for Rural Shortage Area and Non-Shortage Area Patients 

with AMI: 1991-1993 4-19 

TABLE 4-7 Treatment Patterns for Disabled and Non-Disabled Patients with AMI: 

1991-1993 4-20 

TABLE 4-8 Treatment Patterns for Black and White Patients with TIA: 1991-1993 4-21 

TABLE 4-9 Treatment Patterns for Medicaid-Eligible and Non-Eligible Patients with 

TIA: 1991-1993 4-22 

TABLE 4-10 Treatment Patterns for Urban Poor and Non-Poor Patients with TIA: 1991-1993 4-23 

TABLE 4-11 Treatment Patterns for Rural Poor and Non-Poor Patients with TIA: 1991-1993 4-24 

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TABLE OF TABLES 

PAGE 

TABLE 4-12 Treatment Patterns for Urban Shortage Area and Non-Shortage Area Patients 

withTIA: 1991-1993 4-25 

TABLE 4-13 Treatment Patterns for Rural Shortage Area and Non-Shortage Area Pahents 

WithTIA: 1991-1993 4-26 

TABLE 4-14 Treatment Patterns for Disabled and Non-Disabled Patients with TIA: 

1991-1993 4-27 

TABLE 4-15 Changes in Medicare Allowed Charges, 1991-1993 4-28 

TABLE 4-16 Price Variables Used in Episode of Care Regressions 4-29 

TABLE 4-17 AMI Weighted Means 4-30 

TABLE 4-18 TIA Weighted Means 4-31 

TABLE 4-19 Regression Results: MPS Impacts on AMI Pahents 4-32 

TABLE 4-20 Regression Results: MPS Impacts on TIA Patients 4-34 

TABLE 4-21 Impact of Specialists on Utilization of Tests and Procedures 4-36 



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1.0 EXECUTIVE SUMMARY 



1.1 Statement of the Problem 



Beginning in January 1992, Medicare introduced a fundamental change in the method 
used to reimburse physician services. This new Medicare Fee Schedule (MFS) dramatically 
altered the relahve prices paid to physicians, thereby altering the incentives to provide one 
type of service relative to another. Relative payment levels were greatly increased for visits, 
and reduced for most types of diagnostic tests and surgical procedures. How physicians have 
responded to these payment changes is of critical importance to policymakers who are 
concerned about ensuring access to care for Medicare beneficiaries. Much of the historic 
concern and attenhon has focused on the impact of fee reductions (e.g., the Medicare fee freeze, 
the OBRA-87 overpriced procedure payment reductions, etc.), as Medicare has limited 
experience with increases in payment levels. Policymakers tradihonaUy have feared that 
physicians wUl respond to fee reductions by increasing the number of services they provide 
(e.g., the controversial "volume offset" assumption). It is possible, however that physicians 
will respond by providing fewer procedures to their Medicare patients, particularly those 
patients with limited ability to pay coinsurance amounts. 

Work by McGuire and Pauly (1991) has shown that physician responses to payment 
reductions will depend on the relative magnitude of income and substitution effects. On the 
one hand, a Medicare fee cut reduces income leading physicians to provide more of all services 
(not just the services whose price was cut); this is the "income effect" of a price change. On the 
other hand, after the fee reduction there is less return to the physician from providing that 
service to Medicare patients relative to other patients, encouraging the physician to provide 
less to Medicare patients and more in other, better-paying markets (the "substitution effect"). 
Income effects are hypothesized to be stronger for those physicians with relatively larger 
shares of their practice devoted to the services whose fees were cut and with relatively larger 
Medicare shares. Substitution effects are hypothesized to be sh-onger when margins (the fee 
for the service minus the cost of providing it) are relatively greater in the non-Medicare market 
and when physicians' Medicare market shares are relatively smaller. Mitchell and Cromwell 
(1995) found considerable support for this model in their study of the OBRA-87 payment 



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reductions. Despite reduced fees. Medicare utilization rates for bypass surgery, joint 
replacement, and cataract extraction increased; these are procedures which represent relahvely 
large practice shares for thoracic surgeons, orthopedic surgeons, and ophthalmologists, 
respectively. By contrast, internists and other medical specialists are not particularly 
dependent on any of the endoscopic procedures whose fees were cut (like bronchoscopy and 
upper GI endoscopy). Utilization rates for these procedures either feU or remained constant. 

As noted earlier, relatively little is known about physician responses to Medicare fee 
increases . If physicians respond to higher visit reimbursement levels by providing more 
patient contacts, then access to primary care services may have greatly improved. To the extent 
that access to outpatient visits enhances access to other services, such as preventive care, then 
higher visit fees may have a multiplier effect on overall access. Furthermore, higher visit fees 
may encourage physicians to tieat less well-insured Medicare patients (e.g., those without 
private supplemental policies). Alternatively, under a utility-maximizing model of physician 
behavior, higher net revenues per visit may lead physicians to substitute better paying 
Medicare patients for those less able to meet coinsurance amounts. 

Policymakers are vitally concerned about how these payment changes may have either 
improved or exacerbated access problems for more vulnerable populations. Prior theoretical 
and empirical research has shown that physicians do segment their Medicare market based on 
ability to pay (Mitchell and Cromwell, 1982). Most attractive are nonassigned patients, while 
poor patients without supplemental coverage are least attractive as they may not be able to pay 
even the coinsurance amounts. Subgroups of the Medicare population who may be 
particularly vulnerable to any shifts in the supply of physician services include the foUovving: 



• Residents of Health Professional Shortage Areas (HPSAs) and of rural areas more 
generally. These residents already might have been experiencing some 
difficulties in obtaining physician services; did payment changes resulting 
from the MPS exacerbate or improve this problem? 

• Dual (Medicare-Medicaid) eligibles and other poor elderly. Because these patients 
are less financially remunerative, physicians may have cut back services to 
these patients first. Alternatively, increased payment levels for evaluation 
and management services may make them relatively more attractive. 

• Very old and disabled beneficiaries. Because these enrollees may need 
disproportionately more physician services, compared with relatively 



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healthier Medicare enrollees, even small reductions in services could 
produce adverse outcomes. 

• Black beneficiaries. For reasons that are not completely understood, black 
Medicare beneficiaries undergo many procedures at rates well below those 
of white enrollees. Did this utilization gap widen during the transition to the 
MFS? 

For the last five years, both HCFA and the Physician Payment Review Commission 
(PPRC) have been monitoring access to physicians' services. Both agencies have conducted 
extensive analyses, using both claims data and the Medicare Current Beneficiary Surveys. (See 
their annual reports to Congress, as well a special PPRC 1995 report on access.^) Their studies 
have failed to document any barriers to access resulting from the Medicare Fee Schedule. At 
the same time, however, both agencies have documented substantial differences in service use 
across subgroups of Medicare beneficiaries. In particular, black beneficiaries, residents of 
urban poverty areas, and those living in urban HPSAs were significantly less likely to receive 
certain kinds of physician services, compared with others. These differentials have persisted 
throughout the period of MFS tiansition (PPRC, 1995). 

Our study sought to build on this prior research in three critical ways: (1) by over- 
sampling groups of beneficiaries believed to be particularly vulnerable to payment changes; (2) 
by evaluating changes in fi-eatinent patterns for specific episodes of care; and (3) by conducting 
multivariate analyses that measured actual payment changes over time rather than expected 
changes due to the MFS. 



1.2 Methods 

Sample Design and Data 

A stratified random sampling design was used to take advantage of the differential 
impacts of the MFS across geographic areas and to ensure adequate numbers of vulnerable 
beneficiaries. All geographic areas were categorized into six mutually exclusive groups based 
on their expected 1992 payment change under the MFS. All beneficiaries in the 1991 
denominator file were then categorized into one of 60 strata defined by: (1) the six MFS 



1 A complete list of the relevant HCFA and PPRC reports is induded in the References section at the end of this report. 

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payment change areas; and (2) ten population subgroups. The ten groups included nine 
groups of potentially vulnerable beneficiaries: 

• those residing in a rural HPSA; 

• those residing in an urban HPSA; 

• those residing in a rural poverty area; 

• those residing in an urban poverty area; 

• those jointly eligible for Medicaid; 

• those who were black; 

• those who were originally entitled to Medicare because of disability or end- 
stage renal disease; 

• those who were very old (85 years and older); and 

• those residing in any rural area. 

All Medicare beneficiaries not meeting any of these criteria constituted the tenth group. 

A total of 2.6 million beneficiaries were selected. Replacement samples of new eligible 
beneficiaries were later added in 1992 and in 1993, respectively, using the same sampling 
criteria. Medicare Part A claims for acute hospital stays. Part B physician and outpatient 
claims, and denominator records were extracted for all sampled beneficiaries for each of the 
three shidy years (1991-1993). 

In addition to this large national sample, we also selected two medical conditions for in- 
depth study of treatment patterns: (1) patients hospitalized with acute myocardial infarction 
(AMI); and (2) patients hospitalized with transient ischemic attacks (TIA). These conditions 
were chosen because they generally involve "high-tech" diagnostic testing, the results of which 
may lead to subsequent surgery. Many of these diagnostic tests and surgical procedures 
experienced substantial payment reductions under MPS. As a result, physicians may have 
been less likely to provide these services, especially to vulnerable patients. At the same time, 
increased payment for hospital visits under MPS may have encouraged more intensive 
evaluation and management of patients hospitalized with these conditions, especially on the 
part of specialists. Our sample yielded about 19,000 cases of AMI annually, and 9,000 TIA 
cases annually. 

Access Measures 

Three types of access measures were analyzed for the national sample: outcomes, 
utilization, and financial impacts. Outcomes were measured as ambulatory care sensitive 

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(ACS) admissions, i.e., hospitalizations that were potentially avoidable. Utilizahon measures 
included rates of use for a wide range of services, including visits, prevenhve services, and 
high-tech diagnostic and therapeutic procedures. Measure of financial impact included per 
beneficiary coinsurance and extra billing amounts, as well as assignment rates. The episode of 
ca'-e analyses focused on inpatient visits and consultations, diagnostic tests, and surgical 
procedures. 

Calculating MFS Payment Changes 

At the time we selected our sample, data were only available for expected payment 
changes under the MFS. By the time we were ready to conduct our final analyses, however, we 
were able to construct actual MFS payment changes for individual services at the locality level. 
These data were obtained from the Physician/Supplier Procedure Summary files. Thus, the 
payment change variables included in our regression analyses were based on the actual change 
in Medicare payment for the relevant service or procedure. 

Statistical Tests 

T-tests were used to determine the statistical significance of differences in rates between 
vulnerable and non-vulnerable groups, and over time. For the national sample, these 
comparisons were also made by geographic area, where areas had been categorized by the size 
of the actual MFS payment change. 

Multivariate regression techniques (primarily logistic regression) were used to more 
fully evaluate MFS impacts, holding other factors constant. The regression models were based 
on a quasi-experimental design that takes advantage of cross-sectional differences in the 
magnitude of payment changes. Pre-post utilization was compared for vulnerable and non- 
vulnerable beneficiaries in areas experiencing MFS impacts of various magnitudes. This model 
assumes that utilization responses, if they exist, will be greater in areas experiencing relatively 
larger payment changes. Significant differences in the size of the response for vulnerable and 
non-vulnerable beneficiaries that are associated with the magnitude of the MFS price change 
are evidence that the MFS has had a differential impact on access to care. 



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1.3 Results 

1.3.1 Overview 

Little evidence was found that the Medicare Fee Schedule either unproved or worsened 
access for Medicare beneficiaries. While some MFS-related changes in access were 
demonstrated for some vulnerable groups, the actual magnitude of these changes were 
relatively small. Furthermore, the direction of change was not consistently negative or 
positive. Given the large number of access measures used in this study, a significant finding 
for any single measure should not be given undue weight. 

At the same time, we found that substantial access gaps existed for vulnerable 
beneficiaries and that these gaps persisted throughout MFS transition. Of particular concern is 
evidence that access to primary care may actually have worsened for one of the vulnerable 
groups we examined: dual Medicaid-eligibles. 

All Medicare beneficiaries enjoyed reduced out-of-pocket payments over the 1991-1993 
period, including both lower copayments and lower extia billing liability. Lower copayments 
potentially result from a combination of lower fees and/ or lower utilization rates; given that 
overall use did not fall, lower coinsurance amo-Jits would appear to result from payment 
reductions. Decreased extra billing liability resulted from both increased assignment rates over 
this same period, and the balance bill limits imposed on non-participating physicians as part of 
the MFS legislation. 

1.3.2 Access to Primary Care 

MFS Impacts 

Although tabular comparisons were conducted for a wide range of access measures, we 
focused primarily on measures that captured access to primary care. These included: 
outpatient visits, emergency room (ER) visits, ambulatory care sensitive (ACS) admissions, and 
two preventive services (mammography and Pap tests). If higher reimbursement rates 
encouraged physicians to provide more primary care, we would expect to observe more 
outpatient visits, fewer ER visits, fewer ACS admissions, and more preventive services. 
Furthermore, these differences should be more pronounced in areas with relatively larger 
payment increases. 

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• During the 1991-1993 study period, Medicare payments for outpatient ViSits 
increased by about 12 percent. 

Multivariate regression analysis revealed some evidence of diiferential access to 
primary care under the MFS, particularly with respect to outpatient visits. Although 
statistically significant, the actual magnitude of these effects was quite small, however. 
Specifically: 



• Increased outpahent visit payment raised the odds that black beneficiaries 
and female disabled beneficiaries would make at least one outpatient 
physician visit in 1993. 

• At the same time, joint Medicaid eligible and urban poor beneficiaries were 
less likely to visit the physician. Those joint Medicaid eligibles who did see 
the physician made significantly fewer visits. 

• In all instances, the size of the MFS impact was small. The average payment 
increase of 12 percent for outpatient visits raised the odds of a black 
beneficiary seeing the physician by 3.6 percent, or from 0.696 in 1991 to 0.721 
'n 1993. Similarly, the odds of making at least one visit fell by 2.4 percent for 
joint Medicaid eligibles, and the number of such visits (among those with 
visits) declined by one percent. 

• There were no differential MFS impacts for vulnerable groups, except for 
disabled beneficiaries. Increased outpatient visit payments improved their 
odds of receiving mammography. 

• Finally, there was no evidence that increased outpatient visit payments 
lowered the odds of visiting the emergency room or of being hospitalized 
with an ACS condition. 

While MFS impacts were either small or non-existent, substantial differentials in access 
to care were observed for vulnerable subgroups of beneficiaries. In a few instances, these 
differentials actually worsened from 1991 to 1993, independent of the fee schedule changes. 



• Eight of the nine vulnerable groups studied (all but those living in rural 
poverty areas) were significantly less likely to have seen the physician even 
once on an outpatient basis. Those residents of urban poverty areas or rural 
shortage areas who did see the physician, however, made fewer such visits. 

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• On the other hand, while joint Medicaid eligible and disabled beneficiaries 
were less likely to have an outpahent visit, those who did go went 
significantly more often. 

Over the three year study period, non-vulnerable beneficiaries experienced significant increases 
in both the odds of making at least one outpatient visit and in the number of such visits 
(conditional on the first). This greater access to outpatient care was not shared by all, however. 

• The odds that a joint Medicaid eligible beneficiary would make at least one 
outpatient physician declined significantly, from 0.84 in 1991 to 0.77 in 1993. 

• The number of outpatient visits made by those Medicaid-eiigible and 
disabled beneficiaries who succeeded in making at least one visit declined 
over this same time period. 

Consistent with this low rate of outpatient use, ER visit and ACS admission rates were higher 
for many vulnerable groups. 

• Beneficiaries who were very old, black, Medicaid-eiigible, or disabled were 
more likely to both visit the ER and to be hospitalized for ACS conditions. 

• The odds of avoidable hospitalization were also higher for residents of urban 
poverty areas and urban shortage areas. 

Also consistent with limited access to ambulatory care, women in vulnerable groups were less 
likely to receive preventive services. 

• Eight of the nine vulnerable groups (all women except those living in rural 
shortage areas) were significantly less likely to receive either a Pap test or 
mammography over the course of a year. 

• However, the mammography differential for black and white female 
beneficiaries began to close between 1991 and 1993. 

1.3.3 Access to Services During Episodes of Care 

Evaluation of MFS impacts included hospital visits and inpatient consultations, but 
primarily focused on access to diagnostic and therapeutic procedures. For AMI patients, these 

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included echocardiography, cardiac catheterization, PICA, and CABG surgery. For TIA 
patients, these included non-invasive cerebrovascular tests, head CT, brain MRl, cerebral 
angiography, carotid endarterectomy, and anticoagulant therapy (the last proxied by 
prothrombin time tests). In addition, we examined access to specialist care during the inpatient 
stay: having a cardiologist as attending physician in the case of AMI pahents, and a neurologist 
for TIA patients. 

The MFS appeared to have virtually no effect on access to services. 

• Despite dramatic reductions in payment for diagnostic tests and surgical 
procedures, vulnerable patients continued to receive these tests and 
procedures at the same rate as before MFS. 

Utilization differences between vulnerable and non-vulnerable patients were less 
marked or non-existent among AMI and TIA patients. For example: 

• There were no differences in the rate of hospital visits or consultations. 

Nevertheless, difference in use of cardiac procedures shown in other studies also were 
documented here. 



• The odds of undergoing cardiac catheterization or revascularization (PTCA 
or CABG) were significantiy lower for four groups of AMI patients: black, 
Medicaid-eligible, and disabled beneficiaries, and those residing in urban 
poverty areas. 

1.3.4 Financial Liability 



Medicare beneficiaries experienced significant reduction in out-of-pocket liability from 
1991 to 1993, after adjusting for inflation. These reductions were shared by all vulnerable and 
non-vulnerable groups. 

• Coinsurance liability fell by 6 percent (about $12). 

• Extra billing liability fell by two-thirds, or $25 from 1991 to 1993. 



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The extra billing reduction resulted from the greater restrictions imposed on non-participating 
physicians under the MFS, as weU as from increased assignment rates. 

• Assignment rates for physicians' services increased from 65 percent in 1991 
to 75 percent in 1993. 

1,4 Overview of Report 

The remainder of the report consists of three chapters. Chapter 2 describes the sample 
design, data, and statistical methods used. Both descriptive and multivariate analyses for the 
national sample are presented in Chapter 3, while Chapter 4 includes both descriptive and 
multivariate results for the episodes of care analysis. At the end of this report are three sets of 
appendices. Appendix A includes definitions (including diagnosis and procedure codes) of all 
variables used to measure access. Definitions of all price variables (again including procedures 
codes) are presented in Appendix B. Appendix C contains 23 tables showing utilization rates 
for additional services and procedures. Please note that the payment change areas used in 
these tables are based on expected overall payment changes resulting from the MFS, not the 
actual payment changes that are used in Chapter 3. 

The reader should be aware that this report is the final in a series of reports that have 
been produced as part of this cooperative agreement. Using the sample described in this 
report, we wrote the following chapters in HCFA's Reports to Congress on Monitoring Access: 

Mitchell, Janet B., "Appendix IV. Impact of the Medicare Fee Schedule on Access 
to Physician Services", in Report to Congress. Monitoring the Impact of Medicare 
Physician Payment Reform on Utilization and Access. HCFA, 1994. 

MitcheU, Janet B., Rezaul K. Khandker, and Diane N. McPartlin, "Appendix VII. 
Access to Physician Services for Vulnerable Beneficiaries: Impact of the Medicare 
Fee Schedule", in Report to Congress. Monitoring the Impact of Medicare Physician 
Payment Reform on Utilization and Access. HCFA, 1995. 

MitcheU, Janet B., Diane N. McPartlin, and Rezaul K. Khandker, "Appendix XII: 
Impact of the Medicare Fee Schedule on Patterns of Care: Acute Myocardial 
Infarction and Sh-oke Patients", in Report to Congress. Monitoring the Impact of 
Medicare Physician Payment Reform on Utilization and Access. HCFA, 1995. 



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In addition, we published the following article in the Health Care Financing Review based on 
analyses performed under this cooperative agreement: 

Mitchell, Janet B. and Rezaul K. Khandker, "Black-White Treatment Differences 
in Acute Myocardial Infarction", Health Care Financing Revieio 17; 61-70, 1995. 

As part of this same cooperative agreement, we also conducted independent analyses of 
MFS impacts using the Medicare Current Beneficiary Surveys. These analyses were written 
and included in the following chapters in HCFA's Reports to Congress: 



Rosenbach, Margo and Joyce Huber, "Chapter 6: Utilization, Access, and 
Satisfaction with Care Among Noninstitutionalized Medicare Beneficiaries: A 
Baseline Analysis", in Monitoring Utilization of and Access to Services for Medicare 
Beneficiaries Under Physician Payment Reform. Third Annual Report, HCFA, 
DHHS, 1993. 

Rosenbach, Margo L. and Rezaul Khandker, "Appendix V. Changes in 
Utilization, Access, and Satisfaction with Care Among Noninstitutionalized 
Medicare Beneficiaries", in Report to Congress. Monitoring the Impact of Medicare 
Physician Payment Reform on Utilization and Access. HCFA, 1994. 

Rosenbach, Margo L., Killard W. Adamache, and Rezaul Khandker, "Appendix 
VIII. Trends in Utilization, Access, and Satisfaction with Care Among 
Noninstitutionalized Medicare Beneficiaries: 1991-93", in Report to Congress. 
Monitoring the Impact of Medicare Physician Payment Reform on Utilization and 
Access. HCFA, 1995. 

In addition, we published the following article in the Health Care Financing Review under this 
cooperative agreement: 

Rosenbach, Margo L., Killard W. Adamache, and Rezaul K. Khandker, 
"Variations in Medicare Access and Satisfaction by Health Status: 1991-93", 
Health Care Financing Review 17: 29-50, 1995. 



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2.0 DATA AND METHODS 

2.1 Sample Design 
2.1.1 National Sample 

The national sample was selected using a stratified random sampling design to: (1) take 
advantage of the differential impacts of the MFS across geographic areas; and (2) to ensure 
adequate numbers of vulnerable beneficiaries living in areas experiencing different levels of 
MFS payment change. The sample was drawn from the Health Care Financing 
Adniinistration's 1991 denominator file. All persons eligible for both Parts A and B, resident of 
the 50 states and D.C., and not enrolled in an HMO constituted the uiuv'erse, with a total N of 
31,857,201. All beneficiaries in the denominator file were categorized into one of 60 strata 
defined by (1) expected MFS payment change and (2) vulnerable population subgroup. 
Following is a description of the methods used to define these strata and sample selection 
procedures. 

2.1.1.1 MFS Payment Change 

All geographic areas were categorized into six mutually exclusive groups based on their 
expected 1992 payment change under the MFS compared to the old system: (1) 8 percent or 
greater reduction; (2) greater than or equal to a 5 percent reduction, but less than an 8 percent 
reduction; (3) greater than or equal to a 3 percent reduction, but less than a 5 percent reduction; 
(4) greater than or equal to a 1 percent reduction, but less than a 3 percent reduction; (5) 
between a 1 percent reduction (not inclusive) and a 2 percent increase (not inclusive); and (6) 2 
percent or greater increase. The first two categories represent areas with fairly substantial 
payment reductions, the third and fourth have more modest reductions, and areas in the final 
two categories experienced little change or even increases in payments. 

These groups were defined based on the Health Care Financing Administration's 
calculation of MFS payment changes expected in 1992 for each reasonable charge locality, 
taking into accoimt the transition rules in effect for the first year of MFS implementation. 



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These changes represented the percent change in payments per service compared with the pre- 
MFS payment system. These estimated payment changes were based on projechons from 1989 
data and may not accurately reflect actual change under the fee schedule. At the tmne the 
sample was selected, alternative data sources for calculahng the actual payment change more 
accurately were not available. i 

We cross-walked all reasonable charge localities to MSAs and state rural areas. The 
expected MFS payment change was then merged onto the deuominator file, based on the MSA- 
rural area in which the beneficiary resided. We then categorized the payment change variable 
into six groups based on a frequency distribution of beneficiaries. 

2.1.1.2 Vulnerable Population Subgroup 

Nine groups of potentially vulnerable beneficiaries were identified: (1) those residing in 
a rural Health Professional Shortage Area (HPSA); (2) those residing in an urban HPSA; (3) 
those residing in a rural poverty area; (4) those residing in an urban poverty area; (5) those 
jointly eligible for Medicaid; (6) black beneficiaries; (7) those originally entitled to Medicare 
because of disability or ESRD; (8) the "very old" (85 years and older); and (9) those residing in 
any rural area. Unlike the MFS payment change areas, these groups are not mutually 
exclusive. Beneficiaries who did not meet any of these criteria constituted a tenth group, the 
nonvuLnerable. 

All of the variables needed to identify these vulnerable population subgroups were 
available from the denominator file except residence in an HPSA or poverty area. Considerable 
effort was required to construct these measures, as described below. 

HPSAs: A complete list of HPSAs was published in the September 1991 Federal 
Register. A small number of HPSAs encompass entire counties, but the majority are defined as 
much smaller geographic units: census tracts, census county subdivisions, enumeration 
districts, and the like. The smallest geographic imit available on the denominator file is the zip 
code, however. We purchased cross-walks linking census tracts (CTs) to zip codes and census 



»As described below, we subsequently obtained data that allowed us to estimate the actual MFS impact by locality. These payment 
change data are used in the analyses in this report. 

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county subdivisions (CCDs) to zip codes from two private vendors. These cross-walks 
included data on the percent of a zip code's population included in a given CCD or CT. These 
crosswalk, combined with detailed zip code maps, enabled us to eventually identify all but a 
few of the HPSAs in the Federal Register. A Medicare beneficiary was defined as living in a 
shortage area if 50 percent or more of the zip code's population had been identified as residing 

in an HPSA. 

Poverty Areas: A Medicare beneficiary was defined as living in a poverty area if they 
resided in a zip code in which 30 percent or more elderly households were below the 1991 
poverty threshold for a retired couple. Information on the 1991 income distribution of elderly 
households by zip code were obtained from a commercial vendor of census data. Because the 
federal poverty threshold is expressed in nominal dollars without any adjustment for 
geographic cost-of-living differences, we developed and applied a methodology for making 
this adjustment. A paper describing this methodology is available from the authors. 

2.1.1.3 Sample and Sub-sample Selection 

Once HPSA and poverty area designation had been determined, all beneficiaries 
in the denominator file were assigned to one of 60 strata (6 payment change categories*10 
population groups). Sampling algorithms developed by Dr. Martin Frankel were used to select 
cases within each stratum. Sampling weights were calculated as the inverse of the probability 
of selecHon. A total of 2,637,180 beneficiaries were selected in 1991. Table 2-1 presents the 
unweighted sample sizes by vulnerable group category. Table 2-2 presents the frequency 
distribution of the vulnerable population subgroups, after weighting to reflect their population 
prevalence. The importance of over-sampling is clear; a 5 percent random sample would have 
yielded only 34,000 residents of rural shortage areas, for example, compared with our actual 
sample of over 250,000. 

AU surviving members of the 1991 sample were included in the 1992 sample. 
Individuals who became Medicare-eligible for the first time in 1992 were also assigned to one of 
the 60 strata. A sample from this group was selected to replace members of the 1991 sample 



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TABLE 2-1 

UNWEIGHTED SAMPLE SIZES, 1991 



NATIONAL SAMPLE 



Vulnerable Group ^ 

Urban Shortage Area 

Rural Shortage Area 

Urban Poor Poverty Area 

Rural Poor Poverty Area 

Black 

MedicaJd-EIJgible 

Disabled 

Very Old (85+) 

Any Rural Area 

TOTAL 



M 
224,170 
253,556 
233,966 
374,101 
528,019 
548,534 
681.300 
421,983 
1,026,729 
2,637,180 



Female 

120,716 

143.128 

128,158 

221,017 

291 ,248 

362,447 

266,404 

304,063 

563,159 

1,500,793 



NOTE; * The sum of observations in vulnerable groups is less than the total number of vulnerable tieneficiaries 
due to overlapping individuals. 



SOURCE: Sample of Medicare patients drawn from the 1991 denominator file. 



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TABLE 2-2 

WEIGHTED PROFILE OF NATIONAL SAMPLE, 1991 



Vulnerable Subgroup 

Urban Shortage Area 
Rural Shortage Area 

Urban Poverty Area 
Rural Poverty Area 

Black 

Medicaid-Eligible 

Disabled (original reason for eligibility) 

Very Old (85+) 

Any Rural Area 



Percent of Beneficiaries 

3.5 % 
2.1 

6.2 

1.7 

8.3 
12.1 
15.0 

9.1 
28.2 



Medicare Payment Change Category 



A 



V 



Reduction 1 
2 
3 
4 
5 
Increase 6 



Percent of Beneficiaries(a) 

4.1 % 
11.1 
23.0 
34.7 
18.3 

8.8 



NOTE: 

(a) May not sum to 100% due to rounding. 

SOURCE: Medicare 1991 denominator file. 



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montana\rinalrpt\tab2-2.)(is\nd 



that died. A sample of newly-eligible beneficiaries in 1993 was selected in the same way to 
replace members of the 1992 sample that died. 

Descriptive tables for the national sample are based on the full sample of beneficiaries. 
Because of computer limitahons, regressions could not be run on the full sample. Therefore, a 
one-third sub-sample was randomly selected for the regression analyses. This sub-sample was 
selected to ensure that only one year of data was sampled for any individual and that each 
sample member had a one-in-three chance of being selected in any year in which she appeared. 
As a result, the cross-sechon time-series data include different sets of beneficiaries for each 
year. 

The original sample selection process resulted in multiple years of data for most sample 
members. Such a data set requires panel data estimation techniques, such as fixed or random 
effects models, which control for the correlation across observations for the same person over 
time. Panel data models were not considered feasible for our purposes for two reasons. First, 
the sample would be biased because only beneficiaries who survived for three years would be 
included. Second, most of our regressions used binary dependent variables (probability of 
having an office visit or a given surgical procedure), which require logistic regression or probit 
analysis. While fixed and random effects models are widely used with linear regression 
techniques, their use in the context of binary dependent variable models is limited. There are 
some references in the economics literature to fixed effect logit models (Chamberlain, 1980; 
Hsiao, 1986) and random effects probit models (Hsiao, 1986). Both models are extremely 
difficult to conceptualize and estimate. 

Regression models other than panel data models assume the independence of 
observations in the sample. Failure to adjust for the correlation introduced by having multiple 
observations for the same individual can bias coefficient estimates and standard errors. To 
eliminate this panel bias, we selected our sub-sample to preserve the time series nature of the 
data, while avoiding panel data estimation. The sub-sample consisted of one-third of 
observations in each year, with no overlap across years. The final regression sample consisted 
of 899,365 beneficiaries in 1991 and 862,109 in 1993.^ 



^Regressions were run using the 1991 and 1993 samples. We also estimated regression models with the 1991 and 1992 samples. 
Because the results were similar to those for the 1991 and 1993 samples, they are not reported. 

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2.1.2 Episodes of Care Samples 

Utilization of medical care services is driven in large part by a beneficiary's health 
status. Comparisons of per capita utilizahon rates do not permit any adjustment for health 
status, other than relatively crude proxies such as age and sex. For this reason, we a]?o 
conducted analyses of service use during selected episodes of care. Two medical conditions 
were selected: (1) acute myocardial infarction (AMI); and (2) transient ischemic attack (TIA). 
These were selected because they both involve "high-tech" diagnostic testing, the results of 
which may lead to subsequent surgery. Patients with these conditions were selected as 
follows: 

• AMI patients included all patients admitted with a principal diagnosis of 
ICD-9 code 410. xl during the first 9 months (January l-September 30) of 
each study year; and 

• TIA patients included all patients admitted with a principal lCD-9 diagnosis 
code of 435 during the first 11 months (January 1-November 30) of each 
study year. 

These time intervals were selected to allow 90 and 30 days of follow-up, respectively, for all 
AMI and TIA patients. These follow-up time periods have been used in previous studies; see 
Mitchell and Khandker, 1995; Peterson et al, 1994; and Udvarhelyi et al., 1992, for studies of 
utilization for AMI patients, and MitcheU et al, 1996b for a study of patients with TIA. 

Table 2-3 displays the average annual number of AMI and TIA patients in our sample, 
both overall and by vulnerable group. Because some analyses were performed on subsets of 
these patients (e.g., only patients undergoing cardiac catheterization), we also present the 
sample sizes for these analyses. It should be noted that, for some vulnerable groups, sample 
sizes become quite small. 



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TABLE 2-3 

AVERAGE ANNUAL UNWEIGHTED SAMPLE SIZES FOR EPISODE OF CARE ANALYSIS 









AMI 






TIA 
















Patients with Atrial 
















Fibrillation and 








Patients Undergoing 




Patients Undergoing 


without Clinical 




Vulnerable Group 


All 


Cardiac Catheterization 


AN 


Cerebral AnoioqraphY 


Contradindications 




Black 


2,741 




998 


1,789 


68 


75 




Medicaid-Eligible 


3.718 




1,204 


2,378 


91 


169 


NJ 


Urban Poor 


2,394 




798 


1,188 


46 


83 


00 


Rural Poor 


1,725 




687 


1,004 


71 


76 




Urban HPSA 


1.524 




602 


340 


43 


58 




Rural HPSA 


1.627 




684 


704 


43 


57 




Disabled 


4,638 




2,262 


1,716 


138 


112 




TOTAL 


18,938 




7,015 


9.345 


514 


782 



SOURCE; Medicare Part A and Part B claims for a sample of Medicare patients, 1 991 -1 993 



montana\finalrptVtab2-3 xls\nri 



2.2 Data Sources 

The analyses in this report are based on six main data sources: (1) the denominator file; 
(2) MedPAR claims for acute hospital stays; (3) Part B physician and outpatient department 
claims; (4) the physician/ supplier procedure summary files; (5) claims data from a private 
sector insurance plan that offered national coverage; (6) the Area Resource File; and (7) the PPS 
Impact FUe. As discussed earlier, the denominator file was used tc draw the sample; it also 
provided sociodemographic characterishcs for each member of the sample. MedPAR claims 
were used to construct hospital admission rates and surgical rates. Part B claims were used to 
create a wide range of physician utilization measures, as well as summary expenditure data. 
MFS impact variables were estimated from the physician/ supplier piwcedure summary files. 
These data, along with private sector insurance data, were also used to measure the difference 
between Medicare and private prices. Data on market characteristics were drawn from the 
Area Resource File, and hospital characteristics from the PPS Impact file. 

2.3 Variable Measurement and Construction 
2.3.1 Access Measures 

The analysis of the national sample focuses mainly on access to primary care services 
(see Appendix A). We look at four access measures directly related to the utilization of primary 
care services. For the total population we examine office visit rates and emergency room use. 
We assume that high rates of emergency room use may indicate inadequate access to primary 
care services. Separate analyses for women look at rates of office visits, mammography, and 
pap tests. The latter two preventive services are presumably ordered during the course of a 
primary care visit, so that low rates for these services may signal poor primary care access. The 
analysis of the national sample includes a utilization measure for one surgical procedure - 
cataract surgery. (Utilization rates for other surgical procedures were too low in the population 
at large to permit multivariate analysis.) We conducted additional descriptive analyses, 
presented in Appendix C, of rates of use for a wide range of other preventive services, visits, 
and "high-tech" diagnostic and therapeutic procedures. 



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Admission rates for ambulatory care sensitive (ACS) conditions are also examined as an 
outcome measure related to primary care access. These admissions are considered outcomes 
because hospitalizations are potentially avoidable with timely and adequate outpahent care. If 
such admissions are higher for vulnerable populaHons than for comparison beneficiaries, this 
suggests that barriers to care may exist for these vulnerable subgroups. Billings and colleagues 
(1991) have developed a list of 24 ACS conditions applicable to adults based on principal 
diagnosis. 

Financial impacts were examined as a final access measure. Descriptive analyses 
looked at MFS impacts on per enrollee coinsurance and extra billing amounts, as well as 
assignment rates. 

The episode of care analyses considered access for beneficiaries hospitalized for 
treatment of AMI and TIA. For both samples, we looked at hospital visit and consultation 
rates (Appendix A). Our utilization analyses also included specific tests and procedures 
related to each condition. For AMI patients these were: echocardiograms, cardiac 
catheterization, PTCA, and CABG surgery. The TIA analyses included: noninvasive 
cerebrovascular tests, head CT scans, brain MRl scans, cerebral angiography, carotid 
endarterectomy, and anticoagulant therapy (as proxied by prothrombin time tests). 

2.3.2 MFS Impacts 

MFS impacts were measured in two ways. For detailed descriptive tables based on the 
national sample, shown in the Appendix C, we used the expected 1992 payment change under 
the MFS compared to the old system. As described above, geographic areas were categorized 
into six muhiaUy exclusive groups based on this expected payment change. This measure of 
the MFS impact has several limitations. First, it is based on the predicted, rather than actual, 
impact. Second, it is not procedure-specific; instead, it reflects the aggregate expected change 
across aU services. In order develop a more precise measure of the MFS impact, we estimated 
Medicare's achial average allowed charge for selected procedures by pricing locaUty in 1991, 
1992, and 1993. Price changes based on these allo\\'ed charges were then used in descriptive 



2-10 
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and regression analyses. Following is an explanation ot the methods that were used to 
construct these price variables. 

2.3.2.1 Calculation of Medicare Average Price 

The Medicare average price by Medicare payment locality was calculated from the 1991, 
1992, and 1993 physician/ supplier procedure summary files for: office visits, hospital visits, 
inpatient consultations, cataract surgery, mammography, echocardiograms, cardiac 
catheterization, PTCA, CABG, noninvasive cerebrovascular tests, cerebral angiography, carohd 
endartarectomy, CT scans of the head, and MRl scans of the brain. The procedure summary 
file reports the total annual amount of Medicare allowed charges and allowed services in each 
Medicare locality by CPT-4 procedure code. 

The average price in each year was calculated as total allowed charges divided by total 
allowed services. Appendix B lists the procedure codes included in the price calculation for 
each service category. In most cases, the service categories encompass multiple procedure 
codes.3 In these cases, allowed charges and allowed services were summed across procedure 
codes. This produces an average price that is p weighted average of the prices for the 
individual procedure codes included in the category, with weights equal to the number of 
allowed services for a given procedure code in that year. The weighted average does not 
control for changes in the mix of procedures within these service categories over time. 
Therefore, price changes that are calculated based on these average prices reflect the combined 
impact of the MFS price change and any changes in billing practices. This parallels our access 
measures, which measure whether a particular service was received and do not control for 
changes in the procedure code mix. 

In a small number of cases, an average price could not be calculated for a locality, either 
because no data were reported in the Medicare procedure file or because the data produced 
outlier average prices that were clearly in error. In these cases, the price calculation was based 
on data from an adjacent locality. If a usable price could not be calculated for any of the three 



3In some cases the average price calculation was based on a subset of the potential procedure codes within a category to increase the 
homogeneity of the services included. For example, the calculation for cataracts was limited to the most common cataract surgery 
procedure code (cataract removal with intraocular lens implant) and to selected modifier codes. 

2-11 
montana\finalrpt\chap2.doc\bam 



years, (a relatively infrequent occurrence), missing data were replaced by the prices from the 
adjacent locality. If a price was available for any of the three years, then missing prices were 
imputed using rates of change over the same time intervals from an adjacent locality. 

2.3.2.2 Merging Price Data with Analytic Files 

Price data were merged with both the file containing the nahonal sample of Medicare 
beneficiaries and with the episode of care files. The Medicare average price for all three years 
was merged with each observation, so that a percent change over time in the Medicare price for 
a given procedure (the MFS impact) could be attached to each observation. 

Prices were merged with the national sample based on the pricing locality in which the 
beneficiary resided; for the episode of care files, the merge was based on the pricing locality of 
the hospital where treatment was received. A Medicare pricing locality was identified for each 
observation in the analytic files in order to link with the average price data. To assign a pricing 
locality, we created a crosswalk file from ZIP code to county and Medicare pricing locality. We 
applied this crosswalk file to the analytic files, first attempting to assign a pricing locality based 
on benefic-^ry or hospital ZIP code. If no match was found, a second attempt to assign a 
locality was made based on county.^ Remaining non-matches were hand-assigned a pricing 
locality. We were left with a small number of observations (less than 0.1% of the national 
sample; none in the episode of care samples) for which we could not identify a pricing locality. 
This usually arose because ZIP code and county were missing from the file. 

Ideally, prices should be assigned based on physician practice locality. However, this 
was not possible, both because the sources from which our analytic files were created did not 
contain these data and because our files are person-level summaries of utilization which may 
encompass services from mulhple physicians. Beneficiary residence is an imperfect proxy for 
physician pricing locality, although this is unlikely to be a serious problem in areas with 
localities that cover the entire state or other large geographic areas. To the extent that our MFS 
impact variable is measured with error, our results are biased towards null findings. 



^Although some localities are defined by city or other sub-county geographic unit, counties usually are not split between localities. 



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2.3.2.3 Calculation of Private Price 

Regressions using the national sample also include a variable for the percent difference 
between the private and Medicare price for a procedure. Claims data for 1991-1993 were 
obtained from a private insurer that offered coverage nahonwide. Claims data for professional 
services in 1991, 1992, and 1993, were used to calculate an average private price in each year for 
office visits, cataract surgery, and mammography by Medicare pricing locality. Claims for 
covered services in these three categories were selected using the same procedure code 
definitions applied to the Medicare data.5 A Medicare pricing locality code was assigned to the 
claims data based on ZIP code using the crosswalk file.* We then calculated an average private 
price in a comparable marmer to the Medicare price, using the total number of covered 
services^ and covered charges aggregated by locality. 

The average private price for office visits, cataract surgery, and manrmiography was 
merged with the national sample by pricing locality and year. The percent difference between 
the private and Medicare price in that year was then calculated for each of these services. 
Private price data were omitted from the episode of care analyses because the incidence of the 
relevant procedures was too low in our data source. 

2.4 Statistical Tests 
2.4.1 Descriptive Analyses 

T-tests were used to determine the statistical significance of differences in rates between 
groups and over time. All rateb were standardized for age and sex using the direct method. 
For comparisons of very old versus younger beneficiaries, rates were standardized for sex only. 



sProcedure modifier codes, which were used to define the Medicare average price for caUract surgery, were not avaUable in the 
private sector data. Instead, the private price was based only claims for cataract surgeries where the type of service was surgery. 

'The percentage of private insurance claims that matched with a pricing locality was lower than that achieved for the analytic fUes, 
particularly in certain states in some years. In the most extren.e case, a pricing locality could not be assigned to more than 40 percent 
of the claims for Virginia in 1991. Nearly all of these claims were found to contain an invalid zip code. 

Tin some cases, apparent errors in the number of services produced implausibly low prices. Therefore, we set the maximum number 
of services per claim to two for cataracts and to ten for office visits. 

2-13 
montaiui\finalrpt\chap2.doc\l»m 



For comparisons based only on female members of the sample (mammography and pap tests), 
only an age standardization was used. Because of the complex nature of the sample design, 
weighting and standard error adjustments were required in all analyses. 

2.4.2 Regression Analyses 

Multivariate regression techniques were used to more fully evaluate MFS impacts for 
selected dependent variables, holding factors other than the Medicare payment change 
constant. Logistic regression was used for binary dependent variables. Log-normal models 
were used for continuous variables. The model is based on a quasi-experimental design that 
takes advantage of cross-sectional differences in the magnitude of payment changes by 
comparing the utilization trend between 1991 and 19938 for vulnerable and nonvulnerable 
beneficiaries in areas with large versus small MFS impacts. This model assumes that 
utilization responses, if they exist, will be greater in areas experiencing larger payment 
changes. Significant differences in the size of the response for vulnerable and nonvulnerable 
beneficiaries that are associated with the magnitude of the MFS price change are evidence that 
the MFS has had impact on access to services for vulnerable populations. 

The basic multivariate model estimated for both the national sample and the episodes of 
care analyses was: 

USEu = f(PRlCE91jk; MFSjW Y93^ MFSjk*Y93u V; V*MFSjk*Y93t; OTHER) 

where USEik = utilization of the i-th service in year t; 

PRICE91jk = average 1991 Medicare allowed charge for service j in Medicare pricing 

locality k; 

MFSjk = percent change in the average allowed charge for service j in locality k from 

1991 to 1993; 
Y93t = 1 if year is 1993; otherwise; 



«As noted previously, we also estimated regression models for the time trend between 1991 and 1992. The results did not differ 
appreciably from the 1991 and 1993 models. 

2-14 
mont£ma\finalrpl\chap2.doc\bam 



MFSjk*Y93i = interaction of MFSii, and Y93,; 

V = vector of dummy variables for vulnerable groups; 

V*MFSjk*Y93t = vector of interaction terms; 

OTHER = vector of beneficiary/ patient, market area, or hospital characteristics. 

PR1CE91 and MPS control for baseline utilization differences across Medicare pricing localities.^ 
Baseline utilization levels are expected to be higher in areas with relatively higher fees 
(PRICE91). Similarly, historical growth rates in use may be greater in areas with greater 
historical price changes and larger expected changes under the fee schedule (MPS). 
Coefficients on the terms of primary interest (MPS*Y93 and V*MPS*Y93) would be biased if 
such differences existed and MPS was omitted from the model. 

Y93 measures the average utilization time trend between 1991 and 1993 for a given 
service. MFS*Y93 captures the difference in the time trend for localities with large versus small 
price changes. Because this term is further interacted with V in another variable, the MPS*Y93 
interaction by itself measures the MPS effect on the time ti-end for the omitted group, 
nonvulnerable beneficiaries. V*MPS*Y93 reflects the differential impact of the MPS price 
change on utilization time trends for vulnerable groups relative to the nonvulnerable. i" The 
coefficients on these interaction terms are the primary focus of our analyses. Significant 
coefficients suggest that the implementation of the MPS has had an impact on utilization for 
vulnerable groups. The sign of these coefficients may be positive or negative, with the 
interpretation depending on the dependent variable in the regression. A positive significant 
coefficient in the office visit regressions, for example, indicates that an increase in office visit 
fees following the implementation of the MPS improved access for a vulnerable group relative 
to the nonvulnerable. In contrast, a negative coefficient in the emergency room use regression 
is evidence that the MPS price increase improved access for the vulnerable because lower rates 
of emergency room use signal better access to primary care services. 



' In some models, the service for which PRICE91 and MFS are measured is the same as the dependent variable (i.e., i=j). to other 
cases, the relevant price variables differ from the dependent variable. The specific price variables used in each regression are 
described in Chapters 3 and 4. 

iDWe also considered including PR1CE91*Y93 and V'MFS. These terms were dropped because they were highly coUinear with other 
variables in tlie model. 

2-15 
montana\ f inalrpt\cha p2. doc\ bam 



Baseline utilization differences between vulnerable and nonvulnerable beneficiaries are 
captured by the vulnerable group variables included in V. The OTHER vector incorporates 
other beneficiary or patient characteristics that are believed to have an effect on uhlization, as 
well as hospital or market area characteristics. The variables included in OTHER differ for the 
national sample and episode of care analyses. The specific variables used in these models are 
described in the following chapters. 

The results of logistic regressions are reported as odds ratios, while parameter estimates 
are shown from the log-normal models. As in the descriptive analyses, all models were 
estimated with weights and standard errors have been adjusted to account for the complex 
sampling design. 



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3.0 ANALYSIS OF NATIONAL BENEFICLARY SAMPLE 



3.1 Introduction 



The analyses in this chapter examine the impact of the Medicare Fee Schedule on access 
to services by vulnerable beneficiaries within the Medicare population generally. In contrast to 
Chapter 4, which focuses on beneficiaries with specific conditions, here we consider measures 
that potentially affect all beneficiaries. As described in Chapter 2, these analyses mainly view 
access using several indicators of the utilization of primary care services. In addition, we look 
at effects on a common surgical procedure (cataract extraction) and on patient financial liability. 
MFS impacts on most of these services are explored using both descriptive and regression 
analyses. We omitted the financial liability measures from the regression analyses because it 
was not possible to define a meaningful measure of the price change due to MFS 
implementation. Further descriptive analyses were undertaken for an additional set of services 
(Appendix C). Some of these services are explored in greater depth in the episodes of care 
analyses in Chapter 4. 

The indicators of primary care access are utilization of outpatient visits and emergency 
room services, as well as hospital admissions for ambulatory care sensitive (ACS) conditions. 
Outpatient visits include physician visits in office, cliruc, hospital OPD, and all other 
ambulatory care settings. (Emergency room and home visits are excluded.) The outpatient 
visit rate is a direct measure of primary care access, while high rates for the latter two measures 
signal potentially inadequate access to primary care services. For female beneficiaries only, we 
look at receipt of two preventive services-Pap tests and mammography. Cataract surgery, 
which is relatively common among the general Medicare population, is also exanuned. 
Definitions of these services are shown in Appendix A. The beneficiary financial liability 
measures are: coinsurance liability, extra billing liability, and the assignment rate. 

The analyses for the national sample look at MFS impacts on utilization for the nine 
groups of potentially vulnerable beneficiaries described in Chapter 2. These groups are: 



• the "very old"; 

• blacks; 

• dual Medicaid eligibles; 

• the disabled; 

3-1 

montana\ f inalrpt\ chap3. doc\ nd 



residents of rural areas generally; 

residents of an urban poverty area; 

residents of a rural poverty area; 

residents of an urban Health Professional Shortage Area (HPSA); and 

residents of a rural HPSA. 

As noted previously, the sample was selected to ensure adequate representation of vulnerable 
groups. The unweighted numbers of beneficiaries in each of the vulnerable groups was shown 
in Chapter 2. There are more than 200,000 sample members per year in the smallest vulnerable 
groups, the urban poor and residents of urban shortage areas. Even after selecting the one- 
third sample for regression analyses, these sample sizes should be more than adequate to 
detect any differences that exist between vulnerable and non-vulnerable beneficiaries. 

3.2 Descriptive Results 
3.2.1 Price Changes 

In order to capture MFS impacts, we calculated average annual allowed charges for 
three services: outpahent visit, mammography, and cataract surgery. These means were 
constructed from the Physician/ Supplier Procedure Summary Files for each of the three study 
years, based on the charge locality in which the beneficiary resided. (This process was 
described in detail in SecHon 2.3.2.1.) 

Table 3-1 presents the mean allowed charge for each service over the study period. As 
expected, payment for outpatient visits increased substantially, almost 12 percent from 1991 to 
1993. To the extent that higher payment for outpatient visits improves access to primary care, 
we would expect more outpatient visits, and fewer ER visits and ACS admissions, as a result. 
Since preventive services also are likely to be provided (either directiy or on referral) during 
routine visits, we would expect higher visit payments to increase the probability of receiving 
mammography screening or Pap tests. It is possible, however, that the provision of 
mammography is determined more by its own reimbursement than that of outpatient visits; 
we see in Table 3-1 that Medicare allowed charges for mammography fell 12 percent over the 
same time period. 

Medicare payments for cataract surgery (cataract extiaction plus lOL insertion) also 
were considerably lower in 1993 than in 1991: about $200 or 17 percent less. This decline is all 



3-2 

montana\ f inalrpt\ cha p3.doc\ nd 



the more remarkable, given the very extensive cuts imposed earlier on cataract surgery as part 
of the OBRA overpriced procedure reductions. 

Table 3-1 also shows the change in fees for a major private payer over the same tinie 
period, as well as the percent difference between Medicare and private fees. Increases in 
outpatient visit reimbursement under the MFS appears to have closed the gap somewhat 
between Medicare and other payers, as private payer fees rose relatively slower. Private 
payments for outpatient visits averaged 26.6 percent more than Medicare payments in 1991; by 
1993, this differential had narrowed to 19 percent. Private reimbursement for mammography 
and cataract surgery fell from 1991 to 1993 at almost the same rate as Medicare fees. Private 
fees remained higher than those of Medicare, although the differential for cataract surgery was 
relatively small. 

In order to more easily evaluate differential utilization trends, we classified beneficiaries 
based on size of the MFS impact in their locality. For analyses of outpatient visits, ER visits, 
ACS admissions, and preventive services (manTmography and Pap tests), we compare 
utilization across areas categorized by the outpatient visit price change. Comparison of 
cataract surgery rates were made across areas categorized by the cataract price change. These 
categories should be distinguished from those used in tables published in earlier reports 
(including our chapters in HCFA's 1993, 1994, and 1995 Reports to Congress) and from those 
displayed in Appendix C of this report. These earlier tables had categorized payment change 
based on expected area-level impacts, averaged across all services; here, we use actual areas 
impacts, calculated for individual services. 

Four price change areas were created based on the change in the outpatient visit 
allowed charge between 1991 and 1993: (1) no change or a reduction; (2) an increase of 
between 1-12 percent; (3) an increase between 13-18; and (4) greater than an 18 percent increase. 
Three price change areas were established for cataract fees: (1) a reduction of 20 percent or 
more; (2) no change, or a reduction of less than 20 percent; and (3) a price increase. These price 
change categories were selected based on the empirical distribution of beneficiaries across 
localities. 

Tables 3-2 through 3-10 show the results of descriptive analyses on utilization in 1991, 
1992, and 1993 for the national sample. Utilization is presented by vulnerable population 
group and by price change area. Statistical tests were calculated for the differences between 
vulnerable and non- vulnerable groups in each year (indicated by an "a" superscript) and for 

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the time trend behveen 1991 and 1993 within each vulnerable and non-vulnerable group 
(indicated by a "b" superscript). Tests were performed by MFS payment change area and 
across all payment change areas. The following sections describe the results of these 
comparisons. 

3.2.2 Outpatient Visits 

Aggregating across all payment change areas and aU beneficiary groups, the number of 
outpatient visits grew steadily over the study period, increasing by 3 percent from 1991 to 1993. 
However, the actual increase was small, less than 0.2 visits over a two-year period. This 
increase was significant in each of the four payment change areas, although there was no 
uniform pattern in the magnitude of the increase. The smallest percentage increase occurred in 
areas with the largest payment change (2% in area 4), which is counter-intuitive, while the 
largest increase (4%) was observed in area 2, which had only a modest price increase. 

The "All Areas" columns of Table 3-2 show that outpatient visit rates differed 
significantly for beneficiaries in the vulnerable and non-vulnerable comparison groups in 1991, 

1992, and ^ 993. Vulnerable sub-populations generally had fewer outpatient visits per capita 
than the non-vulnerable. The exceptions were Medicaid-eligible and disabled beneficiaries, 
who had significantly more visits. This may be due in part to their poorer health status. 

All non-vulnerable comparison groups showed significant increases between 1991 and 

1993. In contrast, two vulnerable groups, residents of rural poverty areas and Medicaid 
eligibles, had significant decreases. The disparity is particularly striking for Medicaid dual 
eligibles, who experienced a 3 percent decrease in visits as compared to a 4 percent increase for 
non-crossover beneficiaries. With the exception of residents of rural shortage areas, all other 
vulnerable groups also experienced significant mcreases over time. Nonetheless, the time 
trend differences for the vulnerable and non-vulnerable do not appear to be associated with 
MFS price changes. For all vulnerable groups, beneficiaries in the largest price increase areas 
showed either no change in the number of outpatient visits over time or a significant reduction, 
whereas those in areas with a price reduction showed either an insignificant change or a 
significant increase. In contrast, with the exception of beneficiaries residing in non-poor areas 
that experienced fee reductions, there was a significant increase in the number of outpatient 
visits for beneficiaries in the comparison groups in all payment change areas. 

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3.2.3 Emergency Room Visits and Ambulatory Care Sensitive Admissions 

Vulnerable group beneficiaries generally used emergency rooms at a higher rate (Table 
3-3) and had more ACS admissions (Table 3-4) than their non-vulnerable counterparts in aU 
years. This is consistent with lower outpatient visit rates observed in vulnerable groups 
because emergency room use and ACS admissions may signal inadequate access to primary 
care services. Nonetheless, the differences were particularly marked for the two vulnerable 
groups that had more outpatient visits than their non-vulnerable counterparts-Medicaid 
eligibles and the disabled. This supports the hypothesis that their relahvely higher outpatient 
visit rate may be explained by poorer health status. Very old beneficiaries also had strikingly 
higher rates of emergency room use and admission for ACS conditions. While this may be 
explained by poorer health status, their lower use cf outpatient visits does not reflect their 
greater need. An unknown number of our sample may have been residing in a nursing home 
for some or all of the year, a number expected to be particularly high among those aged 85 or 
more. Thus, lower outpatient visit rates for this cohort may be offset by higher rates of 
physician nursing home visits. 

In contrast to other vulnerable groups, residents of rural shortage areas had 
significantly fewer emergency room visits per beneficiary than residents of non-shortage areas 
in 1992 and 1993, although the size of the difference was small in both years. In addition, their 
ACS admission rates did not differ significantiy in 1991 and 1992. 

The time tiends for emergency room use and admissions for ambulatory care sensitive 
(ACS) conditions were not consistent with the overall h-end toward increasing numbers of 
outpatient visits. In theory, these measures, which are indicators of poor access to primary 
care, should fall as the number J outpatient visits rises. Overall, however, the number of 
emergency room visits was unchanged between 19vl and 1993, whUe the number of ACS 
admissions showed a smaU but significant increase of 5 percent. One possible explanation for 
the secular rise in ACS admission rates is the cohort nahire of our sample. Our original 1991 
sample was aging over time, and older beneficiaries appear to be more likely to be hospitalized 
with ACS conditions. In the regressions that follow, we conti-ol for age when estimating the 
probability of ACS admission. 

Other than beneficiaries in areas with price reductions, who had a small significant 
decrease in the number of emergency room visits, beneficiaries in all payment change areas 

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showed either significant increases or no change in the number of emergency room visits and 
ACS admissions, despite a consistent pattern of increasing number of outpatient visits. 
There was considerable variation in the time trend for emergency room use by 
vulnerable and non-vulnerable comparison groups. Blacks, Medicaid eligibles, the disabled, 
and the very old all had significant increases while there was no significant change for their 
comparison groups. Emergency room use declined for residents of shortage areas, but 
increased for beneficiaries in non-shortage areas. Both residents of rural poor and non-poor 
areas had increasing numbers of emergency room visits, while the rate fell for the urban poor. 
There were no significant changes for residents of urban or rural areas generally. These 
differing time trends for vulnerable and non-vulnerable beneficiaries do not appear associated 
with MFS price changes. 

3.2.4 Mammography and Pap Tests 

Changes in preventive service utilization over our short study period need to be 
evaluated within the context of Medicare coverage restrichons. First, both screening 
mammography and Pap tests are relatively new Medicare benefits, becoming covered in 1991 
and 1990, respectively. Second, neither is an annual benefit; screening mammography is 
covered every two years and Pap tests only every three years. Thus, an apparent decline in use 
could simply be the result of an initial peak in demand (when the benefit first became covered), 
followed by a waiting period until eligible again for screening. 

The percentage of female beneficiaries receiving mammography screening (Table 3-5) 
and Pap tests (Table 3-6) declined between 1991 and 1993. In both cases, the magnitude of the 
change was very small. Only beneficiaries in areas with a price reduction for outpatient visits 
had a significant reduction in the mammography rate, while the probability of having a Pap 
test fell significantly in all areas with a price increase. 

The mammography rate fell significantly over time for all non-vulnerable comparison 
groups except beneficiaries under the age of 85. hi contrast, there was either no change or a 
significant increase in the probability of having a mammogram for all vulnerable groups. As a 
result, the gap between vulnerable and non- vulnerable beneficiaries narrowed, although the 
vulnerable continued to be less likely to receive mammography screening. 



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inontana\finalrpt\chap3.doc\nd 



The time trend varied across payment change areas. In areas with fee decreases, all of 
the non-vulnerable comparison groups and four of the nine vulnerable groups experienced a 
decrease in the likelihood of having a mammogram. In contrast, significant changes over time 
for vulnerable beneficiaries in areas with an MFS price increase were mainly positive. On the 
other hand, other than white beneficiaries in areas with the largest price increase, whose 
mammography rate fell, there were no significant changes for non-vulnerable beneficiaries in 
price increase areas. This pattern is consistent with the hypothesis that increasing Medicare 
reimbursement for outpatient visits improved access to mammography screening for women 

in vulnerable groups. 

Pap test rates declined among both vulnerable and non-vulnerable group beneficiaries. 
Significant decreases were more likely to occur in areas with moderate to large outpatient visit 
price increases as compared to those with price decreases or small increases. However the size 
of the decrease does not differ by payment change area or for vulnerable and non-vulnerable 
beneficiaries. Thus, declining Pap test rates would not appear to be related to the fee schedule. 

Finally, it should be noted that substantial utilization gaps exist between vulnerable and 
non-vulnerable groups of female beneficiaries. The probability of receiving either preventive 
service remained significantly lower for all vulnerable groups with the exception of those in 
rural areas. The absolute magnitude of the differences often are large, furthermore. Dual 
Medicaid-eligible women were only half as likely as non-eligible women to undergo 
mammography, for example. 

3.2.5 Cataract Surgery 

The rate of cataract surgeries increased by 5 percent fi-om 1991 to 1993, despite generaUy 
declining Medicare payments (Table 3-7). This is consistent with the McGuire-Pauly model 
which predicts that income effects wiU dominate for physicians with relatively larger Medicare 
shares and whose practices are disproportionately devoted to the procedures whose payments 
are cut. Ophthalmologists derive one-half of their Medicare revenues, and one-quarter of their 
total practice revenues fi-om cataract surgery alone (Mitchell and Cromwell, 1995). 

Other than residents of urban areas generaUy, the rate of cataract surgeries increased 
significantly for aU non-vulnerable comparison groups. Among the vulnerable, only the 
disabled and residents of rural areas (including those in both rural shortage and rural poverty 

3-7 

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areas) showed significant increases. Cataract surgery rates declined significantly for two 
vulnerable groups — residents of urban shortage areas and the very old. (Uhlizahon levels 
were very high to start with, however, for the latter group.) 

3.2.6 Financial Liability 

Financial liability is assessed in three ways: coinsurance payments (Table 3-8), extra 
billing amounts (Table 3-9), and the assignment rate (Table 3-10). We do not present results by 
MFS payment change area. Our financial liability measures are constructed based on all 
physician services; we were not able to construct a corresponding actual MFS payment change 
variable based on all services. Appendix Tables C-9, C-10 and C-11 present descriptive results 
using payment change areas defined by the expected MFS impact, which is defined using all 
services. 

Coinsurance and extra billing amounts are both adjusted for geographic differences in 
cost-of-living. In addition, 1992 and 1993 amounts are expressed in 1991 dollars using the 
change in the all-item Consumer Price Index (CPI) as a deflator. We used the all-item CPl, 
rather than the medical price index, as the deflator because our focus was on beneficiary out-of- 
pocket payments. Therefore, the relevant benchmark is the impact of financial liabUity for 
Medicare services on the amount of money beneficiaries have to spend on other goods and 
services. 

Coinsurance liability was calculated as 20 percent of Medicare allowed charges. Thus, 
differences in coinsurance liability reflect both differences in service use, and inter-area fee 
differences. Changes over time will reflect both changes in service use and relative payment 
changes resulting from the MFS. There were significant differences between the coinsurance 
liability of beneficiaries in all vulnerable and non-vulnerable groups. While coinsurance 
amoimts were lower for residents of shortage areas, residents ol rural poor areas, blacks, and 
residents of rural areas generally, they were higher for beneficiaries in urban poor areas, 
Medicaid eligibles, the disabled, and beneficiaries over 85. Higher rates for the latter three 
groups, at least in part, are likely to reflect higher rates of service use due to poorer health 
status. All vulnerable groups had significantly lower extra billing liability, with the exception 
of residents of rural shortage areas and rural areas generally. The higher extra billing liability 
for these beneficiaries is explained by lower assignment rates in these areas. 

3-8 

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Coinsurance liability feU significantly by $12.10 (6%) from 1991 to 1993, after adjusting 
for inflation. Significant reductions were observed for all beneficiary groups. Residents of 
rural shortage areas, rural poverty areas, and rural areas generally, as well as blacks, 
experienced smaller than average declines. However, coinsurance amounts for all of these 
groups was less than the average in all three years, largely because of lower fee levels in these 
areas. 

There was a dramatic two-thirds reduction of $24.51 in extra billing liability between 
1991 and 1993. This reduction was significant and fairly uniform across all beneficiary groups. 
Beyond an overall decrease in Part B spending, two additional factors explain the decline in 
extra biUing liability: (1) greater restrictions on extra billing introduced with the fee schedule; 
and (2) higher assignment rates. As part of the MFS legislation. Congress capped the amount 
above the fee schedule payment that physicians could bill patients for (in addition to the 
coinsurance). Since MFS payment amounts for non-participating physicians also were set at 95 
percent of the amounts paid to participating physicians, this further restricted the potential 
extra bill amount. It also encouraged more physicians to accept assignment (and thus forego 
any balance billing). 

The role of assignment rates is illustrated in Table 3-10. Assignment rates increased by 
nearly 15 percent from 1991 to 1993. The percentage increase was lower for most vulnerable 
groups compared to non-vulnerable, however assignments rates were also higher for these 
vulnerable populations. The exceptions to this pattern are residents of rural shortage areas and 
rural areas generally, both of which have lower than average assignment rates and enjoyed 
larger than average increases between 1991 and 1993. In summary, none of the three measures 
indicates that fee schedule implementation imposed greater financial liability on vulnerable 
populations. In fact, the extra billing restrictions associated with MFS appear to have greatly 
reduced out-of-pocket liability. 

3.3 Regression Results 

3.3.1 Specification and Estimation 

Regression models were used to estimate MFS impacts, while holding constant other 
factors that might influence service use. The basic regression model is described in Chapter 2. 
The following specification was used for the combined 1991 and 1993 national sample: 

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USE.t = f(PRICE91ik; MFSj^; Y93t; MFSjk*Y93.; V; V*MFSjk*Y93,- BENE; MARKET) 

where USEit = utilization of the i-th service in year t; 

PRICE91jk = average Medicare allowed charge for service j in Medicare pricing locality k 
in 1991; 

MFSjk = percent change in the average allowed charge for service j in locality k irom 
1991 tol993; 

Y93t = 1 if year is 1993; otherwise; 

MFSjk*Y93, = interaction of MFSjk and Y93,; 

V = vector of dummy variables for vulnerable groups; 

V*MFSjk*Y93t = vector of interaction terms; 

BENE = vector of beneficiary characteristics; and 

MARKET = vector of market area characteristics. 

Regressions were estimated for the following dependent variables using the entire 
national sample: 

• probability of an outpatient visit; 

• number of outpatient visits for those with at least one visit; 

• probability of emergency room use; 

• probability of an ACS admission; and 

• probability of cataract surgery. 

Separate regressions were also estimated for female sample members only using the following 
dependent variables: 

• probability of an outpatient visit 

• number of outpatient visits for those with a visit; 

• probability of mammography screening; and 

• probability of a Pap test. 

Separate visit regressions were estimated for female beneficiaries because it was as'^umed that 
referral for mammography screening and Pap tests occurred during the course of the visit. The 
probability of receiving these preventive services is, in part, a function of making an outpatient 

3-10 

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visit. Therefore, we wanted to explore whether any observed changes in the probabUity of 
having a mammogram or a Pap test were consistent with the pattern of changes in visit 
utilization. 

With the exception of the number of outpahent visits, all dependent variables are binary 
and logistic regression was used to estimate the model. Log-normal regression was used to 
estimate equations for number of outpatient visits in order to reduce skewness in the 
dependent variable. 

As described earlier in this chapter, we hypothesized that , with the exception of 
cataract surgery, access to primary care services would be influenced by outpatient visit fees. 
For the outpatient visit, ER visit, ACS admission, mammography and Pap test regressions, 
PRICE91 and MPS were calculated using outpahent visit fees. PRICE91 and MPS were based 
on cataract surgery fees for the cataract regression. An alternative regression was estimated for 
the probability of mammography screening based on mammography fees. It is possible that 
mammography rates are influenced directly by the fee paid for this service rather than by the 
enhanced access to primary care resulting from higher outpatient visit fees. 

The primary coefficients of interest in our model are those associated with V*MPS*Y93. 
They capture differences in the impact of the MPS price change on utilization time trends for 
vulnerable groups relative to the non-vulnerable population. The impact of the MPS price 
change on the non-vulnerable group is reflected in the term, MPS*Y93. In general, a positive 
coefficient for V*MPS*Y93 indicates that a price increase due to the implementation of the 
Medicare fee schedule improved access (i.e., increased outpatient visit use) for vulnerable 
beneficiaries relative to the non-vulnerable population. A positive coefficient also would 
indicate declining relative access in areas where prices fell following MPS implementation, 
assuming MPS effects are symmetric. Emergency room use and ACS admissions are believed 
to be inversely related to outpatient visit access. If higher outpatient visit fees improved access 
to outpatient visits for vulnerable beneficiaries relative to the non-vulnerable, a negative 
coefficient on V*MFS*Y93 would be expected in the emergency room visit and ACS admission 
regressions. This would be interpreted as a desirable outcome. 

The nine vulnerable group variables in our model are: OLD (age greater than or equal 
to 85), BLACK (black), MEDICAID (dual Medicaid eUgibles), DISABLED (disabled), RURAL 
(resident of a rural area), UPOOR (resident of an urban poverty area), RPOOR (resident of a 
rural poverty area), UHPSA (resident of an urban shortage area), and RHPSA (resident of a 

3-11 

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rural shortage area). Beneficiaries who do not fall into any of these categories constihite the 
non-vulnerable group (included in the intercept). 

In addition to vulnerable group dummy variables, dummy variables for other 
beneficiary (BENE) characteristics believed to affect utilization are included in the model: 
MALE (gender) and AGE (age 75 to 84). An additional set of variables control for MARKET 
area characteristics. PRIV_MED is the percent difference between the private and Medicare fee 
for the same service as PRICE91 and MPS in a given regression. We hypothesize that higher 
private prices relative to Medicare will reduce access for Medicare beneficiaries. A variable is 
also included for the number of physicians per 100 population in the beneficiary's county of 
residence. A higher physician-population ratio is expected to improve access. The physician- 
population ratio is calculated for primary care physicians (PCAREPOP) for regressions using 
the office visit fee, ophthalmologists (OPHTHPOP) for the cataract surgery regression, and 
radiologists (RADPOP) for the version of the mammography regression based on the 
mammography fee. Finally, SHARE65, the proportion of the population that are 65 years or 
older in the county of residence, measures the importance of the Medicare market. 

The same set of variables were included in all regressions.! Means of the dependent 
and independent variables in the regressions for the full national sample are shown in Table 3- 
11. Table 3-12 presents means for female members of the sample. 

3.3.2 MFS Impacts 

Results of regressions on primary-care-related services for the national sample are 
shown in Table 3-13. Table 3-14 presents regression results for the probability of having 
cataract surgery. Table 3-15 contains parameter estimates fi-om regression equations for office 
visits and preventive services for female beneficiaries, whUe results from the mammography 
regression using mammography price variables are found in Table 3-16. Odds ratios are 
shown for all regressions other than those for the log number of office visits, for which 
regression coefficients are presented. 

For categorical variables, the odds ratio is interpreted as the likelihood that a person 
with a given characteristic will receive a service relative to their comparison group. For 
example, the odds of having an office visit was 5.6 percent higher in 1993, ceteris paribus as 



' MALE was excluded from regressions for female beneficiaries only. 

3-12 
monlana\ f inalrpt\ cha p3.doc\ nd 



compared to 1991 (based on the Y93 odds ratio in Table 3-13, col. 1). For continuous variables, 
the odds ratio is interpreted as the change in the likelihood of receiving a service given a one 
unit change in the independent variable. For example, a one dollar increase in the baseline 
Medicare fee for an office visit (PR1CE91) decreases the odds of having an emergency room 
visit by about 2.5 percent. 

The regression estimates in Table 3-13 provide little evidence that MFS implementation 
affected access to ser\ ices for the Medicare non-vulnerable population generally (as reflected 
by MFS*Y93), but do demonstrate some differential impact on access for vulnerable sub- 
populations (reflected in the interactions between the nine vulnerable groups and MFS*Y93). 
The term, MFS*Y93, was not significant in any of these equations, indicating that price changes 
for outpatient visits under MFS did not influence the receipt of outpatient visits by non- 
vulnerable beneficiaries or the probability of having an emergency room visit or an ACS 
admission. Similarly, there is little to indicate a differential impact on vulnerable beneficiaries. 
The interactions of vulnerable group dummy variables and MFS*Y93 are mainly insignificant, 
although there is evidence for some groups that access to outpatient visits may have been 
affected. 

MFS implementation increased the probability that black beneficiaries would make an 
outpatient visit. Evaluating the odds ratio for BLACK*MFS*Y93 at MFS = 12 percent (the 
average percent change in the Medicare fee for an outpatient visit), the odds that a black 
beneficiary would make at least one outpatient visit rose by about 3.6 percent, or (1.003)i2. 
Prior to MFS implementation, blacks were only 69.6 percent as likely as whites to make at least 
one physician visit (based on the odds ratio associated with BLACK), all other things equal. 
MFS raised these odds, but only to 72.1 percent, on average (0.721=0.69*1.036). 

While we hypothesized that the price increase for outpatient visits might improve 
access for vulnerable populations, it appears that MFS implementation may have impeded 
access for Medicaid dual eligibles and residents of urban poor areas (although in both cases, 
the effect is significant only at the 10 percent level). Again evaluating the impact at a 12 
percent price increase, the odds that a Medicaid crossover beneficiary would make at least one 
outpatient visit feU by about 2.4 percent, while that of a beneficiary living in an urban poverty 
area fell by about 3.6 percent. As was the case for blacks, the impact of this change in the odds 
was relatively small. Medicaid eligibles were about 82 percent as likely as non-eligibles to have 
an outpatient visit prior to MFS implementation and about 80 percent as Kkely after. Similarly, 

3-13 

montana\finalrpt\chap3.doc\nd 



the odds for urban poor beneficiaries fell from about 81 percent to 78 percent. There is also 
evidence that the number of these visits fell for those Medicaid-eligible and rural beneficiaries 
with at least one such visit. The magnitude of the effects are again small, however. The 
average 12 percent increase in the outpatient visit fee only changed the number of visits by 
about one percent for both groups. 

The cataract surgery regression (Table 3-14) showed no evidence of MFS impacts on 
utilization for either vulnerable or non-vulnerable beneficiaries. The MFS*Y93 and al' of the 
V*MFS*Y93 odd ratios were insignificant, after adjusting for other factors. 

The outpatient visit results for female sample members were generally similar to those 
for the sample of all Medicare beneficiaries (Table 3-15). Higher MFS fees slightly increased the 
odds of a black beneficiary having an outpatient visit and slightly decreased the odds for dual 
Medicaid eligibles. (However, in this women only regression, the Medicaid coefficient reaches 
significance at the .05 level.) The increased odds that a disabled beneficiary will have an 
outpatient visit approached significance, although the findings for the urban poor are no longer 
significant. Again, the number of office visits for residents of rural areas fell slightly. 

The regression results for the probability of having a Pap test and mammography 
screening indicate that there was a slight decrease (about 3.5 percent) in the odds of having 
these preventive services in areas where the Medicare fee for an outpatient visit rose following 
MFS implementahon. There was no evidence of differential effects for vulnerable beneficiaries 
in the probability of having a Pap test. Relative to the non-disabled, an increase in the fee for 
an outpahent visit was associated with a slight increase (approximately 3.6 percent) in the odds 
of having a manimogram for disabled, female beneficiaries. The net effect of MFS*93 and 
DISABLED*MFS*93, however, is that there was no change in the odds for this population as a 
result of the MFS price increase. 

It is troubling that the odds of receiving preventive services are lower when 
reimbursement for outpatient physician visits increases. Although armual utilization rates may 
be confovmded by coverage restrictions, the regressions have controlled for any time trend 
unrelated to the MFS. (In fact, the odds of receiving mammography is significantly higher in 
1993 than in 1991.) An alternative specification of price, substituting mammography fees for 
visit fees, produces different results, however (Table 3-16). Here the odds ratio for MFS*Y93 is 
also less than one, suggesting lower odds when fees are higher. However, since 
mammography fees fell on average from 1991 to 1993, this means that the odds of receiving 

3-14 

tnontana\ f inalrpt\ cha p3. doc\ nd 



mammography actually increased under the MFS. Lower copayment liability could be a 
possible explanation, but the actual dollars involved are trivial (about $1 difference, using the 
average prices in Table 3-1). There were no differential MFS impacts by vulnerable group 
using this specification. 

3.3.3 Differential Use by Vulnerable Patient Groups 

Neither the descriptive or regression analyses provide much evidence that MFS 
implementation had a differential impact on access to services for vulnerable populations. Yet, 
our descriphve findings indicated substantial baseline utilization differences between 
vulnerable and non-vulnerable populations. Regression results for the main effects of 
vulnerable group dummy variables confirm these descriptive findings even after controlling for 
other beneficiary and market characteristics. With few exceptions, we find poorer access to 
services for vulnerable Medicare populations. 

All vulnerable beneficiary groups, other than residents of rural poverty areas, were 
significantly less likely to have an outpatient visit than non-vulnerable beneficiaries (Table 3- 
13). Blacks and the disabled were each approximately 30 percent less likely to have an 
outpatient visit than their non-vulnerable counterparts. This is a particular concern given the 
presumably poorer health stahis of the disabled. Very old beneficiaries also were significantly 
less likely to make at least one outpatient visit. However, as noted earlier, we were unable to 
assess nursing home residence for sample members. Descriptive results shown in the 
appendix show significantly higher nursing home visit rates for those aged 85 plus, suggesting 
that a disproportionate number of these very old beneficiaries are institutionalized. 

For those beneficiaries with at least one outpatient visit, beneficiaries who are eligible 
for Medicaid, disabled, or live in a rural poverty area have greater numbers of visits than the 
non-vulnerable. Combined with the fact that they were less likely to have a visit, this may 
indicate that those who succeed in accessing these services do so for more serious conditions. 
Residents of urban poverty and rural shortage areas were both less likely to have an outpatient 
visit and have fewer visits if they have any. 

The regression results for emergency room use and ACS admissions, which show 
higher rates for many vulnerable groups, are consistent with limited access to primary care 
services. The odds for Medicaid dual eligibles (nearly twice as high), and disabled beneficiaries 

3-15 

montana\ final q5t\chap3.doc\ nd 



(more than 60 percent higher) are particularly alarming. If this retlects poorer health status, 
their lower outpatient visit rates are all the more disturbing. 

Residents of urban poverty and urban shortage areas also were significantly more likely 
to be admitted to the hospital for an ACS condition than the non-vulnerable, although their 
respective odds are only 9 percent and 13 percent greater. The odds ratios for rural vulnerable 
groups are mostly insignificant and in one case (emergency room visits for residents of rural 
areas generally) is significantly lower than the non-vulnerable. Given that the outpatient visit 
regression does not provide evidence of better access to primary care services for these 
vulnerable groups compared to the non-vulnerable, this may reflect poorer access to hospital 
services. 

Several vulnerable groups also were less likely to have cataract surgery (Table 3-14). 
These include blacks (odds ratio=.811), Medicaid eligibles (odd ratio=.931), the disabled (odds 
ratio=.628) and residents of rural areas (odds ratio=.921). On the other hand, the odds that a 
beneficiary 85 years and over will have cataract surgery is about two-thirds greater than that of 
a beneficiary under 75. This undoubtedly reflects the increasing incidence of cataracts as 
beneficiaries age. 

Among female beneficiaries, the odds of having an outpatient visit are lower for all 
vulnerable groups except residents of rural poverty areas and rural areas generally (Table 3- 
15). Medicaid and disabled beneficiaries who had a visit, on the other hand, had more visits 
than non-crossover and non-disabled beneficiaries (9 percent and 13 percent respectively). 
Residents of rural poverty areas made outpatient visits at a somewhat higher rate than the non- 
vulnerable. While their probability of having a visit did not differ significantly, those with at 
least one visit had 7 percent more visits. 

With the exception of rural shortage area residents, all female beneficiaries in a 
vulnerable group were less likely to have a Pap test or mammogram. Dual Medicaid 
beneficiaries had particularly poor access to these services, e.g. mammography screening (odds 
ratio=.556). The vulnerable group results fiom the mammography regression using 
mammography price are similar to those using the outpatient visit price (Table 3-15). 



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3.3.4 Time Trends 

Although we found few uHlization differences attributable to the fee schedule, we did 
find substanhal access gaps for most of the vulnerable groups. In order to determine whether 
these gaps had narrowed or widened over the study period, we re-estimated the equations 
shown in Tables 3-13 to 3-^6, dropping all MFS interactions and substituting interaction terms 
for the vulnerable groups and the year 1993 (e.g., BLACK*Y93, MED1CA1D*Y93, etc.). 

The outpatient visit regressions showed a trend toward both a greater probability of 
having an outpatient visit and an increasing number of such visits between 1991 and 1993 for 
non-vulnerable beneficiaries (Table 3-17). The time tiend did not differ significantly for most 
vulnerable groups so that there was no change in relative access during our study period. 
However, it appears that the gap between Medicaid and non-Medicaid dual eUgibles in access 
to outpatient visits has widened over time. At baseline, the odds of an outpatient visit for 
Medicaid eUgibles was only 0.84. This differential widened by an additional 7 percent by 1993 
(as indicated by the odds ratio of 0.931 for MED1CAID*Y93). Furthermore, although Medicaid 
dual eUgibles had about 8 percent more outpatient visits (conditional on having any) in 1991, 
this difference narrowed to about 4 percent between 1991 and 1993. Disabled and rural 
beneficiaries also exhibited a negative time tiend in the number of outpatient visits, though the 
magnitudes were smaU. 

Between 1991 and 1993 the odds of having an emergency room visit increased sUghtly, 
by 4 percent. There was no significant change in the odds of having an ACS admission. 
Furthermore, the time tiends for emergency room use and ACS admission rates did not differ 
for the vulnerable and non-vulnerable. The result for residents of urban shortage areas in the 
emergency room use regression was marginaUy significant at the 10 percent level. 

The likeUhood of having cataract surgery also did not change over this time period. 
While the very old showed a negative time trend for cataract surgery relative to beneficiaries 
less than 75 (Table 3-18), it was only significant at p<.10. At baseUne, the very old had a 
substantially higher Ukelihood of having cataract surgery. 

The outpatient visit results for women were similar to those for the overall sample 
(Table 3-19). As was observed among Medicare beneficiaries generaUy, access to outpatient 
visits eroded during our study period for dual Medicaid eUgible women compared to non- 
eUgibles. There was no secular change between 1991 and 1993 ui the probabiUty of either a Pap 

3-17 

montana\ f inalrpt\chap3.doc\ nd 



test or mammography screenmg being performed. However, there was evidence that the 
substantial baseline access gaps for blacks and the disabled narrowed somewhat over this hn^e 
period. 



3-18 

montana\finalrpl\chap3.doc\nd 



TABLE 3-1 

CHANGES IN MEDICARE FEES AND RELATIVE PRIVATE-MEDICARE FEES 











Percent 




1991 


1992 


1993 


Chanqe 


Outpatient Visit 
Medicare Fee ($) 
Private Fee ($) 


$28.60 
36.20 


$30.50 
37.50 


$32.00 
38.10 


11.9% 
5.2 


Difference of Private from 


26.6 % 


22.9 % 


19.1 % 


_ 


Medicare Fee (%) 










Mammoqrapliv 
Medicare Fee ($) 
Private Fee ($) 


$42.36 
58.58 


$38.42 
54.10 


$37.23 
53.31 


-12.1 
-9.0 



Difference of Private from 38.3 % 40.8 % 43.2 % 

Medicare Fee (%) 



Cataract Suraery 
Medicare Fee ($) 
Private Fee ($) 


$1,270.27 
1,482.41 


$1,097.72 
1,284.33 


$1,058.77 
1,240.88 


-16.6 
-16.3 


Difference of Private from 
Medicare Fee (%) 


16.7 % 


17.0 % 


17.2 % 


"" 



SOURCE: Medicare Physician/Supplier Summary Procedure files and private insurer claims, 1991-1993. 



3-19 



montana\finalrpt\tab3-1 xls\nd 



TABLE 3-2 

AVERAGE NUIWBER OF OUTPATIENT VISITS STRATIFIED BY ACTUAL MFS PAYMENT CHANGE AND VULNERABLE POPULATION GROUP, 1991-1993 (age-sex adjusted per beneficiary) 



ACTUAL MFS PAYMENT CHANGE FOR OUTPATIENT VISITS 



I 

to 
o 



Vulnerable 


Fee Reduction 




1-12% Increase 


13-18% Increase 


18% 


+ Increase 




ALL AREAS 




PoDulation 


1»1 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


Shortaqe Areas 

All Shortage Combined 

Urban 

Rural 
Non-Shortage 


5.62* 
5.63' 
4.35- 
6.17 


5.70' 
5.71' 
4.52* 
6.22 


5.79 "" 
5.81 •" 
4.69" 
6.31 " 


4.71 ' 
4.80 ' 
4.51 ' 
522 


4.79' 
4.84' 
4.66' 
5.35 


4.80'" 
4.83' 
4.72 '" 
5.44 " 


4.72 ' 
4.97 
4.41 • 
4.96 


4.77' 
5.06 
4.44' 
5.10 


4.76' 
5.12 " 
4.34 '" 
5.13" 


4.47' 
4.64 
4.38' 
4.66 


4.50' 
4.66 
4.41 ' 
4.72 


4.40 "° 
4.57' 
4.31 '" 


4.74 ' 
4 93 ' 
4.43" 
5.13 


4.79 ' 
4.99 ' 
4.49 ' 
5.24 


4.77 '" 
4,99 '" 
4.44 ' 
5,30" 


Poor Areas 
All Poor Combined 
Urban 

Rural 
Non-Poor 


5.88' 
5.89' 
4.23' 
6.18 


5.95' 
5.95' 
4.57' 
6.24 


6.18" 
6.19' 
4.41 ' 
6.30 


4.96' 
5.03 ' 
4.26' 
5.21 


4.97" 
5.05' 
4.32 ' 
5.34 


4.96' 
5 03 • 
4.40 '" 
5.43" 


4.87 • 
4,74 ' 
5,15' 
4.96 


4.99 ' 
4.90 ' 
5.18' 
5.09 


5.02 '" 
4.97 •" 
5.12 
5.12 " 


4,84' 
4.70 
4.94 ' 
4.64 


4.78' 
4.63' 
4.89' 
4.70 


4.74" 
4.60'" 
4.84 •" 
4.74" 


5.09' 
5.15 
4.89' 
5.11 


5.13' 
5.20' 
4.89' 
522 


5,17'" 
5,26 '" 
4,86 '" 
5,28" 


Races 

Black 
White 


5.49' 
6.25 


5.59' 
6.29 


5.51 ' 
6.39" 


4.66' 
5.31 


4.77' 
5.42 


4.75 '" 
5.52 " 


4.69 ' 
5.06 


4.76' 
5.17 


4.79 '" 
5.20 " 


4.47 ' 
4.74 


4,49 ' 
4,77 


4.49' 
4.80 " 


4.70 ' 
5.21 


4.78' 
5.30 


4.77 '" 
5.36" 


Medicaid Elialble 

Yes 

No 


7.19 ' 
6.01 


7.09* 
6.09 


7.23' 
6.17" 


5.79' 
5.13 


5.77' 
5.27 


5.61 '" 
5.38" 


5.28' 
4.92 


5.30 ' 
5.06 


5.12 " 
5.11 " 


5.40' 
4.57 


5,34' 
4,63 


5.13 '" 
4.69" 


5 73' 

5.04 


5.70 ■■ 
5,16 


5,55 '" 
5,24" 


Disabled 

Yes 

No 


6.60' 
6.10 


6.64' 
6.15 


6.65' 
6.25" 


5.53' 
5.15 


5.64' 
5.28 


5.63 •" 
5.38" 


5.29* 
4.91 


5.43' 
5.04 


5,39 '" 
5,08" 


5.04 ' 
4.61 


5,06' 
4,67 


5.02 ' 
4.70" 


5.45' 
507 


5 54 ' 
5,18 


5.51 "■ 
5.24 '' 


Aqe 

85+ Years 
Less than 85 


5.23' 
6.17 


5.20' 
6.23 


5.35 '" 
6.32 " 


4.36' 
5.21 


4.53' 
5.34 


4.49 '" 
5.43" 


3.98' 
4.98 


4.06 ' 
5.11 


4.05'" 
5.15" 


3.92 ' 
4.67 


3,98' 
4,73 


3.94' 
4.76 " 


4,27 ' 
5.13 


4,37 ' 
5,24 


4 35 '" 
5.30" 


Area of Residence 


5.04' 
6.17 


5.31 ' 
6.22 


5.65 '" 
6.30" 


4.78' 
5.27 


4.95" 
5.39 


5.06 '" 
5.47" 


4.83' 
5.03 


4.87 ' 
5.21 


4.84' 
5.28" 


4.61 • 
4.70 


4,68 
4.74 


4.65 ' 
4.83" 


4.73 ' 
526 


4.82 ' 
537 




Rural 
Urban 


4.82 "■ 
5.45" 


ALL BENEFICIARIES 


6.14 


6.20 


6.29" 


5.19 


5.32 


5.40" 


4.95 


5.08 


5.11 " 


4.65 


4.71 


4.74 " 


5.11 


5,21 


5.27 " 







NOTES: 

• Significantly ditferent rrom the comparison oroup at the 05 level 
" Significantly different from 1991 to 1993 at the 0.06 level, 

SOURCE: CHER analysis of Medicare Part B claims and denominator tile (or a sample of beneficiaries 



iriontana\fin.iltpr\uitj.l ;■ ^l',\na:j 



TABLE 3-3 

AVERAGE NUMBER OF EMERGENCY ROOM VISITS STRATIFIED BY ACTUAL MFS PAYMENT CHANGE AND VULNERABLE POPULATION GROUP, 1 991 -1 993 (age-sex adjusted per beneficiary) 











ACTUAL MFS PAYMENT CHA* 


-SE FOR OUTPATIENT VISITS 










ALL AREAS 






Fee Reduction 




1-12% Increase 




13-18% Increase 


18% 


+ Increase 






PoDulation 


1991 


1992 


1993 


1991 1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


Shortage Areas 

All Shortage Combined 

Urban 

Rural 
Non-Shortage 


0.54' 
0.54" 
0.27' 
0.31 


0.36' 
0.36' 
0.26 
0.29 


0.38 •" 
0.38'" 
0.34" 
0.30 


0.41 • 0.37 • 
0.41 ' 0.39 ' 
0.42 ' 0.32 ' 
0.32 0.31 


0.39 '" 
0.41 • 
0.34 '" 
0.32 


0.35' 
0.38 ' 
0.31 
0.32 


0.33 ' 
0.37 ' 
0.28' 
0.31 


0.34 
0.39' 
0.30'" 
0.33" 


0.29 
0.35' 
0.26' 
0.29 


0.29 

0.35' 
0.26' 
0.29 


0.32 '" 
0.37 '" 
0.29 "" 
0.31 " 


38 ' 
0.41 ' 
32 ' 
0.31 


34 •■ 
38' 
28 ' 
0.30 


0.36 '" 
0.39 '" 
0.31 '" 
0.32 " 


Poor Areas 

All Poor Combined 

Urban 

Rural 
Non-Poor 


0.47' 
0.47' 
0.38' 
0.30 


0.36' 
0.36' 
0.39' 
0.28 


0.39 "" 
0.39 '" 
0.41 
0.29 


0.39 ' 0.38 • 
0.39 ' 0.38 ' 
0.41 ' 37 ' 
0.32 0.30 


0.41 •" 
0.41 •" 
0.39 "■ 
0.32 


0.39 ' 
0.39 ' 
0.37 " 
0.31 


0.36' 
0.35' 
0.37' 
0.30 


0.39' 
0.38' 
0.41 '" 
0.33" 


0.37' 
0.39' 
0.35 ' 
0.29 


0.37' 
0.38' 
0.35' 
0.28 


0.40'" 
0.40" 
0.40 "" 
0.30" 


0.40 ' 
0.41 ' 
0.37 ' 
0.31 


37' 
0.37' 
0.36 ' 
0.30 


0.40' 
0.40 "" 
0.40 '" 
0.32" 


Races 

Black 
White 


0.55' 
0.31 


0.43' 
0.29 


0.45 " 
0.30 


0.46 ' 0.46 ' 
0.32 0.30 


0.49 '" 
0.32 


0.46' 
0.31 


0.44 ' 
0.30 


0.47' 
0.33" 


0.47 ' 
0.28 


0.48 ' 
0.26 


0.51 •" 
0.30 " 


0.47 " 
0.31 


0.45 ' 
0.29 


0.48 "" 
0.31 


Medicaid Eligible 

Yes 

No 


0.67' 
0.28 


0.59' 
0.26 


0.62 •" 
0.27" 


0.72 • 0.71 ' 
0.29 0.27 


0.74 '" 
0.28 


0.70 ' 
0.28 


0.68" 
0.27 


0.72 •" 
0.29 


0.64' 
0.25 


0.65' 
0.25 


0.69 '" 
0.26 


69 " 
0.28 


0.67 ' 
026 


0.71 •" 
0.28 


Disabled 

Yes 

No 


0.61 " 
0.30 


0.54' 
0.27 


0.57 '" 
0.28 


0.59 • 0.57 ' 
0.30 0.28 


0.60' 
0.29 


0.56' 
0.29 


0.55' 
0.28 


0.59 '" 
0.30" 


0.53" 
0.27 


0.53' 
0.26 


0.57 '" 
0.28" 


0.57 ' 
0.29 


0.55 ' 
0.27 


59 -' 
29 


Aqe 

85+ Years 
Less than 85 


0.55' 
0.32 


0.52' 
0.29 


0.55- 
0.30" 


0.53 ' 0.54 ■ 
0.32 0.30 


0.55 '" 
0.32 


0.54' 
0,31 


0.54' 
0.30 


0.57 •" 
0.33" 


0.48' 
0.29 


0.49' 
0.28 


0.50'" 
0.30" 


0.52 ' 
0.31 


0.52 ' 
0.30 


0.54 '" 
0.31 


Area of Residence 

Rural 
Urban 


0.28' 
0.33 


0.26' 
0.29 


0.30 
0.31 " 


0.38 • 0.34 • 
0.32 0.30 


0.36 '" 
0.32 


0.32 
0.32 


0.31 
0.30 


0.34 '" 
0.33 


0.29 
0.30 


0.29 
0.29 


0.31 " 
0.31 


032 
0.32 


0.31 ' 
0.30 


0.33 ' 
0.32 


Al L BENEFICIARIES 


0.32 


0.29 


0.31 " 


0.33 0.31 


0.33 


0.32 


0.31 


0.33" 


0.29 


0.29 


0.31 " 


0.32 


0.30 


0.32 

































NOTES: 

* SIgniTlcantly difterent from th« comparison group at the 0.05 level 
" Slgniricantly difterent from 1991 to 1993 at the 05 level, 

SOURCE: CHER analysis o( Medicare Part B claims and denominator file for a sample of beneficiaries 



montanjMinjlrijni.iDJ J kI;\uA. 



TABLE 3-4 



AVERAGE NUMBER OF AMBULATORY CARE SENSITIVE (ACS) ADMISSION RATES STRATIFIED BY ACTUAL MFS PAYMENT CHANGE AND VULNERABLE POPULATION GROUP, 1991-1993 
(age-sex adjusted per 1 ,000 Ijeneficiaries) 











ACTUAL MFS PAYMENT CHANGE FOR OUTPATIENT VISITS 










ALL AREAS 




Vulnerable 


Fee Reduction 




1-1 2 '/.Increase 




13-18% Increase 




18% + Increase 






PoDulation 


1991 


1992 


199? 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


Shortaqe Areas 

All Shortage Combined 

Urban 

Rural 
Non-Shortage 


79.9" 
80.3' 
48.1 ■ 
56.0 


82.1 ■ 
82.7' 
30.7* 
55.8 


89.7'' 
90,2 '" 
37.0" 
58.2 


75.8' 
80.6* 
63.8' 
58.9 


77.3' 
83.7' 
61.5 
59.4 


80.0 •" 
85.8 '" 
66.0' 
61.9 


71.4' 
74.4' 
67.7 
66.9 


72.9" 
75.8' 
69.6 
67.8 


77.1 '" 
81.0'" 
72.5" 
70.2 


61.1 
65.8" 
58.4 
59.7 


62.6' 
68.0" 
59.6 
58.9 


67.9 "" 
73.9 "" 
64.6" 
61.8 


71.3' 
77.1 " 
62 4 
60.7 


72.9 ' 
79.6 " 
62.7 
60.9 


77.0 '" 
83.6 '" 
66.9 '" 
63 4 " 


Poor Areas 

All Poor Combined 

Urban 

Rural 
Non-Poor 


75.4' 
75.5' 
54.3 
54.2 


74.4' 
74.5' 
54.7 
54.3 


82.6 •" 

82.7 '" 
45.7 
56.1 


78.2' 
78.0" 
80.1 • 
58.5 


79.5' 
79.4' 
80.6' 
59.0 


83.7 '" 
84.2 '" 
79.3' 
61.5 


79.4' 
72.6' 
94.7' 
66.0 


82.3 " 
76.5* 
94.9' 
66.8 


87.1 "" 
81.9 "" 
98.5 '" 
69.2 


81.5" 
74.7" 
86.6' 
58.5 


82.1 ' 
74.5' 
87.9' 
57.8 


89.3 "" 
76 2 '" 
99.1 "" 
60.6 


78.5" 
75.8 " 
88.3' 
59.9 


79 7' 
77.1 ' 
89.0 ' 
601 


85,3 '" 
82.5 '" 
95 2 " 
62 6 " 


Races 

Black 
White 


85.2* 
55.5 


86.7' 
55.4 


92.3 •" 
5P2 


84.6' 
58.3 


85.0' 
58.8 


88.6 '" 
61.1 


84.7' 
66 


88.3" 
66.8 


92 6 '" 
69.0 


80.3' 
58.1 


83.8' 
57.2 


88.5 "" 
60.3 


83.8' 
59.8 


85 8 " 
600 


89 9 •" 
62 5 " 


Medicaid Eligible 
Yes 

No 


122.1 ' 
49.4 


125.0 ' 
48.9 


127.4 '" 
51.1 


132.5 • 
52.4 


132.8* 
52.8 


140.0 " 
54.4 


151.4" 
58.1 


154.1 ' 
58.6 


155.5 • 
60.5 


132.0 ' 
51.4 


133.5 " 
50.3 


135.5 ' 
52.8 


135.6 " 
53.2 


137.1 ' 
53.2 


141.2 "" 
55.1 " 


Disabled 

Yes 

No 


111.1 ' 
52.0 


113.1 • 
51.9 


113.6'" 
54.5 


109.7' 
54.2 


112.8' 
54.6 


113.4'" 
57.1 


115.6' 
61.3 


123.4 " 
61.5 


123.4 '" 
64.0 


106.9 ' 
54.0 


106.8 " 
53.7 


1110' 
56.4 


110.6' 
55.7 


1141 ' 
557 


115.3 '" 
58.3 " 


Aqe 

85+ Years 
Less than 85 


128.7' 
55.1 


133.5 ' 
54.7 


129.7 *" 
57.2 


127.1 ' 
58.0 


129.3 ' 
58.4 


130.4 '" 
60.7 


140.4 ' 
65.1 


141.4 ' 
65.9 


144.0 ' 
68.1 


125.6" 
58.0 


124.7 " 
57.3 


127.0 " 
60.1 


130.1 " 
59.4 


131 6 ' 
59.5 


132 8 '" 
62 " 


Area of Residence 

Rural 
Urban 


44.4' 
57.6 


50.7 
57.2 


50.0' 
59.9 


66.5' 
58.4 


66.2' 
59.1 


69.2 " 
61.5 


75.1 " 
62.3 


76.0 ' 
63.2 


78.8 '" 
65.5 


64.1 " 
55.4 


64.6 ' 
53.5 


67.2 '" 
57.0 


68 0" 
58.6 


68.5 " 
58.8 


71.2 •" 
61.4 " 


ALL BENEFICIARIES 


57.2 


57.0 


59.7 


59.8 


60.3 


62.8" 


67.1 


68.0 


70.5 


59.8 


59.1 


62.2 


61.3 


61.5 


64 2 ' 



NOTES: 

■ SIgnKlcantly different from the comparison group at the 0.05 level 
' Significantly different from 1991 to 1993 at the 0,05 level 

SOURCE: CHER analysis of Medicare Part A clairris and denominator tile for a sample of beneficiaries 



montjnj\l.naiipt\tjt.i ■! . is:n.ri; 



TABLE 3-5 



PERCENT OF FEMALE BENEFICIARIES RECEIVING MAMMOGRAPHY STRATIFIED BY ACTUAL MFS PAYMENT CHANGE AND VULNERABLE POPULATION GROUP, 1 991 -1 993 
(age-adjusted percent of female beneficiaries) 



Vulnerable 
Pooulation 



Fee Reduction 



1991 



ia§2 



1993 



ACTUAL MFS PAYMENT CHANGE FOR OUTPATIENT VISITS 



1-12% Increase 



1991 



1992 



1993 



13-1 8% Increase 



1991 



1992 



1993 



18% + Increase 



1991 



1992 



1993 



ALL AREAS 



1991 



1992 



1993 



Shortage Areas 

All Shortage Combined 

Urban 

Rural 
Non-Shortage 

Poor Areas 

All Poor Combined 

Urban 

Rural 
Non-Poor 

Races 

Black 
White 

Medicaid Eligible 

Yes 

No 

Disabled 

Yes 

No 

Age 

85+ Years 
Less than 85 

Area of Residence 

Rural 
Urban 

ALL BENEFICIARIES 



22.6 ' 23.5 ' 

22.6 • 23.6 ' 

26.2 " 191' 

30.8 30.1 



24.3" 
24.3" 
21.6" 
31.5 



22.3" 
31.7 



17.4' 
32.2 



24.4" 
30.8 



1.2' 
31.4 



29.4 
30.5 

30.4 



24.4' 
24.4' 
19.2 • 
30.6 



22.4' 
30.9 



17.3' 
31.5 



24.1 ' 
30.1 



8.0' 
30.7 



27.5' 
29.8 

29.8 



23.2 ' 
23.2 ' 
20.5 '" 
29.1 ' 



23.3 •" 
23.3 •" 
17.9' 
29.7' 



22.3 ' 

29.3" 



16.6' 
30.6' 



23.5 "' 
29.2' 



8.1 ■ 
29.8' 



27.7 
28.8' 

28.8' 



20.7' 
19.7' 
23.5 ' 
27.0 



19.0' 
18.9' 
19.9' 
27.2 



18.1 
28.1 



15.5' 
28.0 



6.1 ' 
27.4 



21.4 • 
20.2 
24.5 
27.6 



19.5 ' 
28.4 



16.4 ' 
28.5 



6.5' 
28.0 



21.2" 
20.1 ' 
23.9 ' 
26.7 



20.0 ' 19.7 " 

19.8' 19.5"' 

22.3 ' 20.9 " 

27.7 26.9 



19.3 " 
27.5 



15.9 ' 
27.8 



21.6" 22.3' 21.6' 

27.1 27.6 26.8 



6.3 ' 
27.3 



25.5 ' 26.4 ' 25.4 ' 
26.9 27.4 26.7 



20.9' 


22.1 ' 


21.1 ' 


19.9 ' 


21.2' 


20.9 '" 


22.2' 


23.0' 


21.2" 


23.8 


24.3 


23.7 


17.2' 


18.3' 


17.9" 


17.7' 


18.6' 


18.0 ' 


16.1 ' 


17.6' 


17.7" 


24.2 


24.7 


24.0 


15.8' 


17.0 ' 


16.8 " 


24.8 


25.1 


24.5 


11.3' 


12.6' 


11.9" 


25.2 


25.7 


25.2 


18.7' 


19.7 ' 


19.4 " 


24.0 


24.5 


23.9 


5.0' 


5.2' 


5.2' 


24.3 


24.9 


24.4 



21.4' 21.8' 21.3' 
25.0 25.5 24.8 



23.8' 


24.0' 


23.4' 


22.4' 


22.8' 


21.9' 


24.6 


24.6 


24.2 


24.6 


25.1 


24.1 


17.5' 


18.5' 


17.9" 


17.9" 


18.6' 


17.8' 


17.2" 


18.5' 


18.0 '" 


24.9 


25.4 


24.4 


13.3' 


15.2' 


14.7" 


25.9 


26.1 


25.0" 


11.8' 


13.1 ' 


12.7 " 


26.3 


26.8 


25.8 


19.1 ' 


19.9 ' 


19.5' 


24.9 


25.4 


24.4 


5.2' 


5.9' 


5.7" 


25.2 


25.8 


24 8 


23.3' 


24.1 ' 


22.9' 


25.7 


26.1 


25.1 



26.7 



27.2 



26.4 



23.6 



24.2 



23.5 



24.5 



25.1 



24.0 



21.7 ' 
20.6' 
23.7' 
261 



19.4 ' 
19.9' 
17.3' 
26.4 



16,9 ■ 
27.2 



13 8 ' 
27.4 



20.6' 
26.3 



5.7 
26.6 



23 3' 
26.8 

25.9 



22.4 ' 
21,3 ' 
24.2 ' 
265 



20.2 ' 
20.6 ' 
18.8 ' 
26.8 



18,2 ■ 
27.4 



14.8 ' 
27.8 



21.3 ' 
26.6 



6.2 
27.1 



24.0' 
27,1 

263 



21,9 ' 
21,0" 
23,3' 
25.6" 



19,6 '° 
20,0' 
18.4 "" 
25,9" 



18,0 ' 
26.5' 



14,2 ■ 
27 0' 



20 7 ' 
25.8" 



6 1 • 
26 3 



23,1 ' 
26.3" 

25,5 " 



NOTES: 

" Significantly difTerent from the comparison group at the 0,05 level, 
'■ Significantly different from 1991 to 1993 at ttie 0,06 level, 

SOURCE; CHER analysis ot Medicare Part B claims and denominator file for a sample of beneficiaries 



nion:and\tinjlfptUdt)> i- iciswn 



TABLE 3-6 

PERCENT OF FEMALE BENEFICIARIES RECEIVING PAP TESTS STRATIFIED BY ACTUAL MFS PAYMENT CHANGE AND VULNERABLE POPULATION GROUP, 1991-1993 
(age-adjusted percent of female beneficiaries) 











ACTUAL MFS PAYMENT CHANGE FOR OUTPATIENT VISITS 










ALL AREAS 




Vulnerable 


Fee Reduction 




1-1 2% Increase 




13-18% increase 




18% 


+ Increase 






PoDulation 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


Shortaae Areas 

All Shortage Combined 

Urban 

Rural 
Non-Shortage 


10.4' 
10.4' 
16.2 
16.8 


10.5' 
10.5' 
10.9' 
17.0 


11.0' 
11.0' 
4.7"' 
16.2 


10.5' 
9.7' 
12.5' 
14.8 


12.6" 
10.5' 
9.8 ' 
14.8 


10.7 " 
10.0' 
12.6 
14.2 " 


11.1 " 
9.8" 
126 
13.1 


11.5' 
10.4' 
12.9 

13.1 


10.9 ' 
10.2' 
11.7 " 
12.2" 


13.4 
12.8' 
13.7 
13.4 


12.8' 
12.0' 
13.3 
13.4 


12.2 "" 
11.6'" 
12.6" 
12.8" 


11.4" 
10.3 ' 
13.1 " 
14.3 


11.4" 
10.4 ' 
13.0 " 
14.3 


11.2' 
105" 
12 4 "" 
13.6 " 


Poor Areas 

All Poor Combined 

Urjan 

Rural 
Non-Poor 


11.5' 
11.5" 
10.5' 
17.3 


11.6' 
11.6' 
9.6' 
17.5 


11.5' 
11.5' 
9.1' 
16.7 


10.3' 
10.2' 
11.7' 
14.9 


10.4 • 
10.4 ' 
11.4' 
14.8 


10.3" 
10.2" 
11.0 •" 
14.3" 


9.1 ' 
8.9" 
9.6" 
13.3 


9.2" 
9.0' 
9.7* 
13.4 


8.6'" 

8.4" 

9.2"" 

12.4" 


10.0" 

11.0' 

9.2" 

13.6 


10.0" 
10.3' 
9.9" 
13.5 


9.5'" 

9.9'" 

9.2 ' 

12.9" 


10.2 ' 

10.3 ' 
9.8 " 

14.4 


10.3 " 

10.4 " 
10.1 " 
14.4 


10.0 •" 

10.1 " 
9.5'" 

13.8" 


Races 

Black 
White 


10.3' 
17.3 


9.7' 
17.5 


99' 
16.7 


9.8" 
15.3 


9.9" 
15.2 


10.0" 
14.5" 


8.6' 
13.6 


8.6" 
13.7 


8.4" 
12.6" 


8.1 • 
14.1 


8.6' 
13.9 


8.3 " 

13.3 " 


9 2 " 
14.8 


9.3" 
14.8 


9 2 " 
14.0" 


Medicaid Eliqible 
Yes 

No 


9.2' 
17.5 


8.9' 
17.7 


8.3 •" 
17.1 


8.5' 
15.3 


8.9 " 
15.2 


8.8' 
14.7" 


7.1 ■ 
13.7 


7.2' 
13.8 


6.5'" 
12.9" 


7.8' 
14.2 


7.7' 
14.1 


7.6' 
13.5" 


8.1 • 
14.9 


8.2 " 
14.9 


79' 
14.3 " 


Disabled 
Yes 

No 


12.6' 
16.8 


12.9' 
16.9 


12.8' 
16.2 


11.6' 
14.8 


11.7' 
14.8 


11.6' 
14.2" 


9.9' 
13.2 


10.6" 
13.3 


9.6' 
12.3" 


11.3' 
13.6 


10.7" 
13.5 


10.5 '" 
12.9 " 


11.2 ' 
143 


113" 
14.3 


11.0"" 
13.7 " 


Age 

85+ Years 
Less than 85 


4.6' 
17.0 


4.6' 
17.2 


4.7" 
16.5 


4.1 ' 
14.9 


4.1 • 
15.0 


3.7"" 
14.5 


3.5" 
13.3 


3.6" 
13.4 


3.1 "" 
12.5" 


3.8' 
13.8 


3.8' 
13.7 


3.3'" 
13.2 " 


4.0" 
14.5 


4.0 • 
14.5 


as"" 

13.9" 


Area of Residence 

Rural 
Urban 


16.2 
16.5 


17.9 
16.6 


15.4 
16.0" 


13.8" 
14.7 


14.1 
14.6 


13.5 
14.1 ' 


12.1 ' 
13.5 


11.8" 
13.8 


11.2'" 
12.7 


12.8 ' 
25.7 


13.0" 
13.7 


12.2 '" 
13.3 


12.9" 
14.6 


12.9 ' 
14.6 


12 3 "" 
14.0 " 


ALL BENEFICIARIES 


16.5 


16.6 


16.0 


14.6 


14.6 


14.0" 


13.0 


13.1 


12.1 " 


13.4 


13.3 


12.7" 


14.1 


14,1 


135" 



" significantly diflerent trom the comparison group at the 05 level. 
" Significantly different from 1991 to 1993 at the 0.05 level. 

SOURCE CHER analysis of Medicare Part B claims and denominator file for a sample of beneficiaries 



monlana\finalrpIMjb:'-ti 



TABLE 3-7 

CATARACT SURGERIES STRATIFIED BY ACTUAL MFS PAYMENT CHANGE AND VULNERABLE POPULATION GROUP. 1 991 -1 993 (age-sex adjusted per 1 ,000 beneficiaries) 



Vulnerable 
Population 



Reduction of 20% or more 



1991 



1992 



1993 



ACTUAL MFS PAYMENT CHANGE FOR CATARACT SURGERY 



No Change or Less 
Than 20% Reduction 



1991 



1992 



1993 



Fee Increase 



1991 



1992 



1993 



1991 



ALL AREAS 



1992 



1993 



UJ 

I 

M 



Shortace Areas 

Ali Shortage Combined 

Urban 

Rural 
Non-Shortage 

Poor Areas 

All Poor Combined 

Urban 

Rural 
Non-Poor 

Races 

Black 
White 

Medicaid Eligible 

Yes 

No 

Disabled 

Yes 

No 

Age 

85+ Years 
Less than 85 

Area of Residence 

Rural 
Urban 

Al I BENEFICIARIES 



40.1 • 


45.2' 


42.8 " 


40.0' 


44.1 ' 


41.3' 


40.1 ' 


46.0' 


43.8° 


43.8 


50.3 


46.0 


39.7" 


45.8" 


44.3" 


38.3' 


44.8' 


42.8" 


41.2" 


46.8' 


45.9" 


43.8 


50.3 


46.0 


32.9' 


38.7' 


37.5 '" 


45.6 


o2.4 


47.2 


47.0' 


50.8 


45.3 


43.2 


50.0 


45.9 


31.8' 


36.9' 


35.0 "' 


45.0 


51.6 


47.2 


51.8' 


58.8' 


50.3' 


43.4 


49.8 


45.7 


42.5 


49.6 


47.4" 


44.4 


50.4 


44.7 



43.6 



50.0 



45.9 



38.8" 


41.9' 


37.2 "" 


39.5 


42.0' 


35.9 '" 


37.3' 


41.8' 


39.7 '" 


40.7 


44.4 


43.1 " 


38.7' 


41.9' 


38.8' 


37.4' 


40.3" 


36.6* 


45.2' 


49.7' 


49.3 '" 


40.7 


44.5 


43.1" 


34 3" 


35.5" 


32.4 '" 


41.8 


45.7 


44.1 " 


43.8" 


47.5" 


45.0" 


40.2 


44.0 


42.5" 


30 5 ' 


34.6" 


31.7 "" 


41.7 


45.4 


44.0" 


51.0' 


52.6" 


48.5 '" 


40.3 


44.1 


42.6" 


40.5 


45.6 


43.7" 


40.6 


43.9 


42.4 



40.6 



44.3 



42.7 



40.8 
35.1 • 
46.1 
46.2 



44.0 
38.8 ' 
65.0 ' 
45.9 



28.9" 
48.6 



49.9 
45.2 



34.8" 
46.9 



54.4' 
45.5 



46.3 
45.6 



45.8 



42.9 
37.7 ' 
47.7 
44.9 



48.2 
45.0 
61.3 ' 
44.6 



29.3 ' 
46.8 



45.8 
44.6 



37.8 ' 
45.5 



58.7 ' 
44.4 



54.4 " 
41.6 

44.8 



48.4' 
44.4' 
51.9 
46,2 



45.8 
41.4 
63.9" 
46.4 



30.9" 
48.6 



48.0 
46.1 



35.6' 
47.5 



49.9 
46.2 



47.9 
45.8 

46.4 



3?.0 ' 


42.4 ' 


38.4' 


39.5' 


42.0 " 


36.6 '" 


38 2 ' 


43 1 " 


41.0"" 


41.4 


45.6 


43.7" 


38.9' 


43.0 ' 


39.7 ' 


37.5' 


40.8' 


37 3' 


44.0 ' 


48.8 " 


48 3 '" 


41.4 


45.6 


43.7 " 


33 9' 


36.1 ' 


33.5" 


42.6 


47.0 


44.8" 


44.6 ' 


48.2 • 


45.1 ' 


40.9 


45.1 


43.2 " 


30.8' 


35.1 ' 


32.5 '" 


42.4 


465 


44.7 " 


51.2' 


53.9 ' 


48.9 '" 


41.0 


452 


43.2 " 


41.1 


46.9' 


44.7 "■ 


41.2 


44.7 


42 8 


41.2 


454 


43.4 " 



NOTES: 

' Significantly different from the comparison group at the 0.05 level. 
" significantly different from 1991 to 1993 at the 0.05 level 

SOURCE CHER analysis of Medicare Part B claims and denominator file for a sample of beneficiaries 



niontaiid\fir.jiipl\tdlj.'. 



TABLE 3-8 

AVERAGE ANNUAL PART B COINSURANCE LIABILITY BY VULNERABLE POPULATION 
GROUPS, 1991-1993 (age - sex adjusted per beneficiary) 







ALL AREAS 






1991 


1992 


1993 


Shortaae Areas 

All Shortage Combined 
Urban 


$191.35' 
204.92 


$181.74' 
192.75 


$178.69'" 
188.67'" 


Rural 


169.69 ' 


164.46' 


163.18 '" 


Non-Shortage 


203.19 


194.53 


191.11 " 


Poor Areas 








All Poor Combined 


202.65 


193.15 


191.10" 


Urban 


207.34 ' 


196.30" 


194.03'" 


Rural 


185.41 ' 


181.79' 


180.74'" 


Non Poor 


202.54 


193.89 


190.40 " 


Races 

Black 


195.45' 


187.40' 


186.80'" 


White 


206.55 


196.95 


192.91 " 


Medicaid Eliaible 
Yes 


260.22 ' 


250.62 ' 


246.25 '" 


No 


196.29 


187.57 


183.89" 


Disabled 
Yes 


244.73 ' 


237.49 ' 


232.36 '" 


No 


197.75 


189.02 


185.62" 


Aqe 

85+ Years 


210.43 ' 


205.29 ^ 


200.78 '" 


Less than 85 


202.33 


193.51 


190.11 " 


Area of Residence 

Rural 


181.30^ 


176.27^ 


174.31 '" 


Urban 


210.79 


200.65 


196.68" 


ALL BENEFICIARIES 


202.55 


193.84 


190.45 " 



NOTES: 

' Significantly different from ttie comparison group at the 0.05 level. 
" Significantly different from 1991 to 1993 at the 0.05 level. 

SOURCE: CHER analysis of Medicare Part B claims and denominator file for a sample of Iseneficiaries. 
Dollars are deflated by the CPI. 



montana\finalrpt\tab3-8.xls\nd 
3-26 



TABLE 3-9 

AVERAGE ANNUAL EXTRA BILLING LIABILITY BY VULNERABLE POPULATIONS GROUPS, 1991-1993 
(age - sex adjusted per beneficiary) 



Shortage Areas 

All Shortage Combined 

Urban 

Rural 
Non-Shortage 

Poor Areas 

All Poor Combined 

Urban 

Rural 
Non Poor 

Races 

Black 
White 

Medicaid Eligible 

Yes 

No 

Disabled 

Yes 

No 

Age 

85+ Years 
Less than 85 

Area of Residence 

Rural 
Urban 

ALL BENEFICIARIES 



ALL AREAS 


1991 


1992 


1993 


$24.88 " 


$16.52 ^ 


$8.72 ab 


16.67 ' 


10.26" 


5.15 ab 


37.99 =■ 


26.35 " 


14.28 ab 


36.70 


23.59 


11.71 b 


16.21 ^ 


9.93^ 


5.28 ab 


15.22' 


9.45" 


5.11 ab 


19.88" 


11.68" 


5.88 ab 


37.66 


24.26 


12.03 b 


10.43" 


6.16" 


2.94 ab 


39.23 


25.22 


12.55 b 


5.91 " 


3.17" 


1 .47 ab 


39.34 


25.43 


12.73 b 


27.66 " 


17.13" 


8.00 ab 


37.02 


23.89 


1 1 .96 b 


30.79 " 


20.44 " 


10.46 ab 


36.21 


23.29 


11.58 b 


39.40 " 


26.51 " 


13.39 ab 


34.77 


21.94 


10.84 b 


36.06 


23.21 


11.55 b 



NOTES: 

• Significantly different from the comparison group at the 0.05 level. 
" Significantly different from 1991 to 1993 at the 0.05 level. 

SOURCE: CHER analysis of Medicare Part B claims and denominator file for a sample of beneficiaries. 
Dollars are deflated by the CPI. 



3-27 



montana\finalrptteb3-9 xls\nd 



TABLE 3-10 

ASSIGNMENT RATE BY VULNERABLE POPULATION GROUPS, 1991-1993 
(age - sex adjusted per beneficiary) 



Shortage Areas 

All Shortage Combined 

Urban 

Rural 
Non-Shortage 

Poor Areas 

All Poor Combined 

Urban 

Rural 
Non Poor 

Races 

Black 
White 

Medicaid Eligible 

Yes 

No 

Disabled 

Yes 
No 

Age 

85+ Years 
Less than 85 

Area of Residence 

Rural 
Urtaan 

ALL BENEFICIARIES 





ALL AREAS 




1991 


1992 


1993 


66.8% ^ 


70.3% ^ 


74.1%="' 


70.4 ^ 


73.2 " 


75.6 '" 


61.2 ^ 


65.8 ^ 


71.9 '^ 


65.0 


69.4 


74.9 " 


71.5 = 


74.3 ^ 


76.8 ^^ 


71.8 ^ 


74.1 ^ 


76.2 ^^ 


70.4 ^ 


74.8 = 


78.6 '" 


64.6 


69.1 


74.7 " 


72.3 ^ 


75.0 ^ 


77.3 '" 


65.0 


69.5 


75.2 " 


88.2 " 


89.7 ^ 


90.3 ^^ 


62.6 


67.2 


73.0 " 


71.7 ' 


75.3 ^ 


78.8 ^^ 


64.4 


68.8 


74.4 " 


73.4 " 


77.9 " 


82.1 ^^ 


64.9 


69.2 


74.6 " 


61.5 ' 


66.7 ' 


73.4 »" 


66.5 


70.5 


75.4 " 



65.1 



69.5 



74.8 



NOTES: 



• Significantly different from the comparison group at the 0.05 level. 
" Significantly different from 1991 to 1993 at the 0.05 level. 

SOURCE: CHER analysis of Medicare Part B claims and denominator file for a sample of tjeneficiaries. 



3-28 



montana\finalrpt\tab3-1 0.xls\nd 



TABLE 3-1 1 

MEANS OF DEPENDENT AND INDEPENDENT VARIABLES IN REGRESSIONS 
FOR NATIONAL SAMPLE 



Variable 


Outpatient Visit 


InfOutpatient Visits) 


ER Visit 


AC Admission 


Cataract Surqerv 


OUTPATIENT VISIT 


0.782 


N/A 


N/A 


N/A 


N/A 


IN(OUTPATIENT VISIT) 


N/A 


1.515 


N/A 


N/A 


N/A 


ER VISIT 


N/A 


N/A 


0.208 


N/A 


N/A 


ACS ADMISSION 


N/A 


N/A 


N/A 


0.055 


N/A 


CATARACT SURGERY 


N/A 


N/A 


N/A 


N/A 


0.035 


Y93 


0.496 


0.500 


0.496 


0.496 


0.496 


PRICE91 


28.597 


28.567 


28.597 


28.597 


1270.270 


MFS 


11.942 


11.919 


11.942 


11.942 


-16.415 


MFS*Y93 


5.923 


5.965 


5.923 


5.923 


-8.149 


OLD*MFS*Y93 


0.576 


0.536 


0.576 


0.576 


-0.782 


BU\CK*MFS*Y93 


0.472 


0.426 


0.472 


0.472 


-0,656 


MEDICAID*MFS*Y93 


0.802 


0.745 


0.802 


0.802 


-1.097 


DISABLED*MFS*Y93 


0.983 


0.904 


0.983 


0.983 


-1.348 


RURAL*MFS*Y93 


2.439 


2.462 


2.439 


2.439 


-2.665 


UPOOR*MFS*Y93 


0.226 


0.203 


0.226 


0.226 


-0.409 


RPOOR*MFS*Y93 


0.147 


0.145 


0.147 


0.147 


-0.154 


UHPSA*MFS*Y93 


0.158 


0.147 


0.158 


0.158 


-0.241 


RHPSA*MFS*Y93 


0.182 


0.178 


0.182 


0.182 


-0.172 


OLD 


0.093 


0.086 


0.093 


0.093 


0.093 


BU\CK 


0.080 


0.070 


0.080 


0.080 


0.080 


MEDICAID 


0.126 


0.116 


0.126 


0.126 


0.126 


DISABLED 


0.158 


0.143 


0.158 


0.158 


0.158 


RURAL 


0.284 


0.285 


0.284 


0.284 


0.284 


UPOOR 


0.059 


0.054 


0.059 


0.059 


0.059 


RPOOR 


0.017 


0.016 


0.017 


0.017 


0.017 


UHPSA 


0.033 


0.030 


0.033 


0.033 


0.033 


RHPSA 


0.021 


0.020 


0.021 


0.021 


0.021 


MALE 


0.419 


0.403 


0.419 


0.419 


0.419 


AGE75 


0.295 


0.314 


0.295 


0.295 


0.295 


PRIV MED 


22.878 


22.734 


22.878 


22.878 


16.930 


PCARE POP 


0.052 


0.052 


0.052 


0.052 


N/A 


OPHTHPOP 


N/A 


N/A 


N/A 


N/A 


0.005 


SHARE65 


13.670 


13.738 


13.670 


13.670 


13.670 


OLD*Y93 


0.048 


0.045 


0.048 


0.048 


0.048 


BLACK*Y93 


0.040 


0.035 


0.040 


0.040 


0.040 


MEDICAID*Y93 


0.065 


0.060 


0.065 


0.065 


0.065 


DISABLED*Y93 


0.080 


0.073 


0.080 


0.080 


0.080 


RURAL*Y93 


0.141 


0.142 


0.141 


0.141 


0.141 


UPOOR*Y93 


0.029 


0.026 


0.029 


0.029 


0.029 


RPOOR*Y93 


0.008 


0.008 


0.008 


0.008 


0.008 


UHPSA*Y93 


0,016 


0.015 


0.016 


0.016 


0.016 


RHPSA*Y93 


0.010 


0.010 


0.010 


0.010 


0.010 



SOURCE: CHER analysis of Medicare Part A claims and denominator tile for a sample of beneficiaries. 



3-29 



nnontana\finalrpt\tab3-1 1 .xls\nd 



TABLE 3-12 

MEANS OF DEPENDENT AND INDEPENDENT VARIABLES IN REGRESSIONS FOR FEMALE BENEFICIARIES 
IN NATIONAL SAMPLE 











Mammography 


Mammography 










(Mammography 


(Outpatient 


Variable 


Outpatient Visit 


ln(Outpatient Visits) 


Pap Test 


Price) 


Visit Price) 


OUTPATIENT VISIT 


0.804 


N/A 


N/A 


N/A 


N/A 


IN{OUTPATIENT VISIT) 


N/A 


1.543 


N/A 


N/A 


N/A 


PAP TEST 


N/A 


N/A 


0.125 


N/A 


N/A 


MAMMOGRAPHY 


N/A 


N/A 


N/A 


0.227 


0.227 


Y93 


0.495 


0.499 


0.495 


0.495 


0.495 


PRICE91 


28.678 


28.630 


28.678 


42.351 


28.678 


MFS 


11.851 


11.855 


11.851 


-10.748 


11.851 


MFS*Y93 


5.870 


5.919 


5.870 


-5.340 


5.870 


OLD*MFS*Y93 


0.726 


0.644 


0.726 


-0.624 


0.726 


BLACK*MFS*Y93 


0.463 


0.443 


0.463 


-0.508 


0.463 


MEDICAID*MFS*Y93 


0.930 


0.867 


0.930 


-0.843 


0.930 


DISABLED*MFS*Y93 


0.680 


0.673 


0.680 


-0.622 


0.680 


RURAL*MFS*Y93 


2.373 


2.403 


2.373 


-1.224 


2.373 


UPOOR*MFS*Y93 


0.229 


0.214 


0.229 


-0.309 


0.229 


RPOOR*MFS*Y93 


0.140 


0.142 


0.140 


-0.090 


0.140 


UHPSA*MFS*Y93 


0.153 


0.147 


0.153 


-0.181 


0.153 


RHPSA*MFS*Y93 


0.173 


0.171 


0.173 


-0.065 


0.173 


OLD 


0.118 


0.103 


0.118 


0.118 


0.118 


BLACK 


0.079 


0.074 


0.079 


0.079 


0.079 


MEDICAID 


0.146 


0.135 


0.146 


0.146 


0.146 


DISABLED 


0.110 


0.107 


0.110 


0.110 


0.110 


RURAL 


0.275 


0.278 


0.275 


0.275 


0.275 


UPOOR 


0.061 


0.057 


0.061 


0.061 


0.061 


RPOOR 


0.016 


0.016 


0.016 


0.016 


0.016 


UHPSA 


0.033 


0.031 


0.033 


0.033 


0.033 


RHPSA 


0.020 


0.019 


0.020 


0.020 


0.020 



AGE75 



0.320 



0.333 



0.320 



0.320 



0.320 



PRIV MED 


22.835 


22.752 


22.835 


40.698 


22.835 


PCARE POP 


0.052 


0.052 


0.052 


N/A 


0.052 


RADPOP 


N/A 


N/A 


N/A 


0.007 


N/A 


SHARE65 


13.642 


13.695 


13.642 


13.642 


13.642 


OLD*Y93 


0.061 


0.054 


0.061 


0.061 


0.061 


BLACK*Y93 


0.039 


0.037 


0.039 


0.039 


0.039 


MEDICAiD*Y93 


0.075 


0.069 


0.075 


0.075 


0.075 


DISABLED*Y93 


0.056 


0.055 


0.056 


0.056 


0.056 


RURAL*Y93 


0.136 


0.138 


0.136 


0.136 


0.136 


UPOOR*Y93 


0.029 


0.027 


0.029 


0.029 


0.029 


RPOOR*Y93 


0.008 


0.008 


0.008 


0.008 


0.008 


UHPSA*Y93 


0.016 


0.015 


0.016 


0.016 


0.016 


RHPSA*Y93 


0.010 


0.010 


0.010 


0.010 


0.010 



SOURCE: CHER analysis of Medicare Part A claims and denominator file for a sample of beneficiaries. 



3-30 



montana\finalrpt\tab3-1 2.xls\nd 



TABLE 3-13 

REGRESSION RESULTS; MPS IMPACTS ON THE PROBABILITY OF AN OUTPATIENT VISIT, 
NUMBER OF OUTPATIENT VISITS, PROBABILITY OF AN EMERGENCY ROOM VISIT, 
AND PROBABILITY OF AN ACS ADMISSION 



Independent 








ACS 


Variable 


Outpatient Visit* 


InfOutDatient Visits)** 


ER Visit* 


Admission* 


PRICE91 


0.991 ^ 


0.0161 ' 


0.975 ' 


0.985 ' 


MFS 


0.996 ' 


0.0027 ' 


0.987 ' 


0.991 ' 


Y93 


1.056^ 


0.0350 ' 


1.041 ' 


1.018 


MFS*Y93 


1.001 


-0.0004 


1.000 


1.002 


OLD*MFS*Y93 


1.001 


-0.0008 


0.998 


0.998 


BLACK*MFS*Y93 


1.003' 


-0.0002 


0.999 


0.997 


MEDICAID*MFS*Y93 


0.998 ^ 


-0.0009 ' 


1.000 


1.000 


DISABLED*MFS*Y93 


1.001 


-0.0007 


1.000 


0.997 


RURAL*MFS*Y93 


0.999 


-0.0011 ' 


0.999 


1.001 


UPOOR*MFS*Y93 


0.997 " 


0.0007 


0.997 


0.997 


RPOOR*MFS*Y93 


1.004 


-0.0005 


1.000 


1.000 


UHPSA*MFS*Y93 


1.000 


-0.0011 


0.998 


0.998 


RHPSA*MFS*Y93 


1.000 


-0.0009 


0.996 


1.000 


OLD 


0.676 ' 


0.0002 


2.323 ' 


3.188' 


BLACK 


0.696 ' 


-0.0098 


1.178' 


1.118' 


MEDICAID 


0.819' 


0.0644 ' 


1.924' 


1.827' 


DISABLED 


0.733 ' 


0.0710' 


1.657' 


1 .674 ' 


RURAL 


0.959 ' 


-0.0063 


0.947 ' 


1.027 


UPOOR 


0.807 ' 


-0.0132" 


1.026 


1.091 ' 


RPOOR 


0.959 


0.0612' 


0.955 


1.070 


UHPSA 


0.877 ' 


0.0017 


1.025 


1.126' 


RHPSA 


0.840 ' 


-0.0608 ' 


0.955 


0.915 


MALE 


0.749 ^ 


-0.0646 ' 


0.996 


1 .099 ' 


AGE75 


1.359' 


0.1457 ' 


1.601 ' 


1 .968 ' 


PRIV_MED 


0.999 ' 


-0.0002 " 


0.996 ' 


1.000 


PCAREPOP 


0.743 


-0.8385 ' 


0.356 ' 


0.071 ' 


SHARE65 


1.014' 


0.0014 ' 


0.997 ' 


1.000 



NOTES: 

• Significant at the 0.05 level. 
" Significant at the 0.10 level. 

* Odds ratio from logistic regression for national sample. 

** Parameter estimate from lognormal regression for sample memtsers with an office visit. 

SOURCE: CHER analysis of Medicare Part A claims and denominator file for a sample of t>eneficiaries. 

montana\finalrpt\tab3-1 3.xls\nd 

3-31 



TABLE 3-14 

REGRESSION RESULTS: MFS IMPACT ON THE PROBABILITY OF CATARACT SURGERY 



Independent 


Cataract 


Variable 


Surqerv* 


PRICE91 


0.999 ' 


MFS 


0.997 ' 


Y93 


0.997 


MFS*Y93 


0.998 


OLD*MFS*Y93 


1.003 


BLACK*MFS*Y93 


1.000 


MEDICAID*MFS*Y93 


1.003 


DISABLED*MFS*Y93 


1.000 


RURAL*MFS*Y93 


1.000 


UPOOR*MFS*Y93 


0.999 


RPOOR*MFS*Y93 


0.S39 


UHPSA*MFS*Y93 


1.003 


RHPSA*MFS*Y93 


1.003 


OLD 


1 .658 ' 


BU\CK 


0.811 ' 


MEDICAID 


0.931 ' 


DISABLED 


0.628 ' 


RURAL 


0.921 ' 


UPOOR 


0.964 


RPOOR 


1.024 


UHPSA 


1.009 


RHPSA 


0.956 


MALE 


0.819' 


AGE75 


2.086 ' 


PRIV_MED 


0.999 


OPHTHPOP 


4.824 


SHARE65 


1.004' 



NOTES: 

' Significant at the 0.05 level. 
" Significant at the 0.10 level. 
* Odds ratio from logistic regression for national sample. 

SOURCE: CHER analysis of f\/Iedicare Part A claims and denominator file for a sample of tieneficiaries. 



montana\finalrpt\tab3-1 4.xls\nd 



3-32 



TABLE 3-15 

REGRESSION RESULTS: MFS IMPACT ON THE PROBABILITY OF AN OUTPATIENT VISIT, 
NUMBER OF OUTPATIENT VISITS, PROBABILITY OF A PAP TEST, AND PROBABILITY 
OF MAMMOGRAPHY FOR WOMEN 



Independent 










Variable 


Outpatient Visit* 


InOutoatient Visits)" 


Pap Test* 


Mammoqraphv* 


PRICE91 


0.991 ^ 


0.0168 ' 


1.017' 


1.011 ' 


MFS 


0.996 ^ 


0.0027 ' 


1.004' 


1.004' 


Y93 


1.059' 


0.0352 ' 


1.015 


1.035' 


MFS*Y93 


1.001 


-0.0006 


0.997 " 


0.997 ' 


OLD*MFS*Y93 


1.002 


-0.0004 


0.998 


1.003 


BLACK*MFS*Y93 


1.004' 


-0.0003 


1.001 


1.001 


MEDICAID*MFS*Y93 


0.996 ' 


-0.0008 


1.002 


0.999 


DISABLED*MFS*Y93 


1.003'' 


-0.0001 


1.001 


1 .003 ' 


RURAL*MFS*Y93 


0.999 


-0.0012 ' 


0.999 


0.998 


UPOOR*MFS*Y93 


0.997 


0.0017 


1.000 


. 0.998 


RPOOR*MFS*Y93 


1.002 


0.0000 


1.001 


1.002 


UHPSA*MFS*Y93 


0.999 


-0.0011 


1.005 


1.001 


RHPSA*MFS*V93 


0.999 


-0.0010 


1.000 


1.001 


OLD 


0.563 ' 


-0.0568 ' 


0.215' 


0.156' 


BLACK 


0.824 ' 


0.0056 


0.764 ' 


0.746 ' 


MEDICAID 


0.760 ' 


0.0864 ' 


0.679 ' 


0.556 ' 


DISABLED 


0.904 ' 


0.1321 ' 


0.865 ' 


0.713' 


RURAL 


0.993 


0.0030 


0.947 ' 


0.947 ' 


UPOOR 


0.864 ' 


-0.0113 


0.765 ' 


0.824 ' 


RPOOR 


1.050 


0.0707 ' 


0.843 ' 


0.860 ' 


UHPSA 


0.893 ' 


0.0019 


0.846 ' 


0.893 ' 


RHPSA 


0.857 ' 


-0.0547 ' 


1.023 


1.003 



AGE75 



1.205 



0.1147 



0.607 



0.571 



PRIV_MED 

PCAREPOP 

SHARE65 



0.999 ' 
0.593 ' 
1.012' 



0.0001 


1.000 


0.995 ' 


•0.9924 ' 


17.995' 


13.579 ' 


0.0012' 


1.014' 


1.012' 



NOTES: 

' Significant at the 0.05 level. 

" Significant at the 0.10 level. 

* Odds ratio from logistic regression for women in national sample. 

** Parameter estimate from lognormal regression for women with an office visit. 

SOURCE: CHER analysis of Medicare Part A claims and denominator file for a sample of beneficiaries. 



montana\finalrDt\tat)3-1 5.xls\nd 



3-33 



TABLE 3-16 

REGRESSION RESULTS: MPS IMPACT ON THE PROBABILITY OF 
MAMMOGRAPHY FOR WOMEN (MAMMOGRAPHY PRICE) 



Independent Variable 

PRICE91 
MFS 
Y93 
MFS*Y93 



Mammography 
(Mammography Price)* 

1.005^ 
1.004^ 
0.998 
0.996 ^ 



OLD*MFS*Y93 

BLACK*MFS*Y93 

MEDICAID*MFS*Y93 

DISABLED*MFS*Y93 

RURAL*MFS*Y93 

UPOOR*MFS*Y93 

RPOOR*MFS*Y93 

UHPSA*MFS*Y93 

RHPSA*MFS*Y93 



0.999 
0.999 
1.001 
0.998 
0.999 
0.997 
0.998 
1.000 
1.000 



OLD 

BLACK 

MEDICAID 

DISABLED 

RURAL 

UPOOR 

RPOOR 

UHPSA 

RHPSA 



0.157' 
0.724 ' 
0.557 ^ 
0.719' 
0.916' 
0.828 ' 
0.869 ' 
0.916^ 
1.029 



AGE75 



0.571 



PRIV_MED 

RADPOP 

SHARE65 



0.998 ' 

999.000 ' 

1.014' 



NOTES: 

" Significant at the 0.05 level. 
'' SigniHcant at the 0.10 level. 
* Odds ratio from logistic regression for women in national sample. 

SOURCE: CHER analysis of Medicare Part A claims and denominator file for a sample of beneficiaries. 



3-34 



montana\finalrpt\tab3-1 6.xls\nd 



TABLE 3-17 

REGRESSION RESULTS: TIME TRENDS FOR THE PROBABILITY OF AN OUTPATIENT VISIT, NUMBER OF 
OUTPATIENT VISITS, PROBABILITY OF AN EMERGENCY ROOM VISIT, AND PROBABILITY OF AN 
ACS ADMISSION 











ACS 


Independent Variable 


Outoatjent Visit* 


ln(OutDatient Visits)** 


ER Visit* 


Admission* 


PRICE91 


0.991 ' 


0.0159' 


0.975 ' 


0.986 ' 


MFS 


0.996 ' 


0.0026 ' 


0.987 ' 


0.991 ' 


Y93 


1.071 " 


0.0499 ' 


1.037' 


1.030 


MFS*Y93 


1.000 


-0.0011 ' 


0.999 


1.001 


OLD*Y93 


1.002 


-0.0108 


1.021 


0.988 


BU\CK*Y93 


1.019 


-0,0138 


1.005 


1.012 


MEDICAID*Y93 


0.931 ' 


-0.0470 ' 


1.014 


0.991 


DISABLED*Y93 


0.980 


-0.0239 ' 


1.010 


0.961 


RURAL*Y93 


1.006 


-0.0113" 


1.008 


0.975 


UPOOR*Y93 


1.015 


-0.0046 


1.018 


1.012 


RPOOR*Y93 


1.013 


-0.0215 


0.993 


0.994 


UHPSA*Y93 


0.968 


-0.0193 


0.927 " 


0.971 


RHPSA*Y93 


0.972 


-0.0284 


0.947 


0.984 


OLD 


0.680 ' 


0.0005 


2.275 ' 


3.161 ' 


BLACK 


0.703 ' 


-0.0044 


1.17C' 


1.088' 


MEDICAID 


0.840 ' 


0.0830 ' 


1.915' 


1.838' 


DISABLED 


0.745 ' 


0.0792 ' 


1.651 ' 


1 .677 ' 


RURAL 


0.950 ' 


-0.0089 " 


0.934 ' 


1.050' 


UPOOR 


0.791 ' 


-0.0074 


1.006 


1.076 '^ 


RPOOR 


0.984 


0.0659 ' 


0.962 


1.068 


UHPSA 


0.889 ' 


&.0056 


1 .056 " 


1.135' 


RHPSA 


0.853 ' 


-0.0544 ' 


0.950 


0.922 


MALE 


0.749 ' 


-0.0b46 ' 


0.996 


1.099' 


AGE75 


1.358' 


0.1455 ' 


1.601 ' 


1.968' 


PRIV_MED 


0.999 ' 


-0 0002 


0.996 ' 


1.000 


PCAREPOP 


0.744 


-0.8458 ' 


0.359 ' 


0.073 ' 


SHARE65 


1.014' 


0.0013' 


0.997 ' 


1.000 



NOTES: 

' Significant at the 0.05 level. 
" Significant at the 0.10 level. 

* Odds ratio from logistic regression for national sample. 

" Parameter estimate from logistic regression for sample members with an office visit. 

SOURCE: CHER analysis of Medicare Part A claims and denominator file for a sample of beneficiaries. 

3-35 



montana\finalrptVtab3-1 7.)()s\nd 



TABLE 3-18 



REGRESSION RESULTS: TIME TRENDS FOR THE PROBABILITY OF CATARACT SURGERY 



Independent Variable 

PRICE91 
MFS 
Y93 
MFS*Y93 

OLD*Y93 

BLACK*Y93 

MEDICAID*Y93 

DISABLED*Y93 

RURAL*Y93 

UPOOR*Y93 

RPOOR*Y93 

UHPSA*Y93 

RHPSA*Y93 

OLD 

BLACK 

MEDICAID 

DISABLED 

RURAL 

UPOOR 

RPOOR 

UHPSA 

RHPSA 

MALE 
AGE75 

PRIV_MED 

OPHTHPOP 

SHARE65 



Cataract 
Surgery* 

0.999 ' 
0.997 ^ 
1.022 
0.999 

0.925 " 

0.970 

0.939 

0.982 

0.992 

0.990 

1.036 

0.922 

0.972 

1.687^ 
0.820 ^ 
0.936 " 
0.632 ^ 
0.928 ^ 
0.974 
1.018 
1.025 
0.949 

0.819^ 
2.086 " 

0.999 
4.816 
1 .004 ^ 



NOTES: 

' Significant at ttie 0.05 level. 
" Significant at the 0.10 level. 

• Odds ratio from logistic regression for national sample. 

SOURCE: CHER analysis of Medicare Part A claims and denominator file for a sample of tseneficiaries. 

3-36 



montana\finalrpt\tab3-1 S.xIsVid 



TABLE 3-19 

REGRESSION RESULTS: TIME TRENDS FOR THE PROBABILITY OF AN OUTPATIENT VISIT, NUMBER OF 
OUTPATIENT VISITS, PROBABILITY OF A PAP TEST, AND PROBABILITY OF MAMMOGRAPHY FOR WOMEN 



Independent 










Variable 


Outoatient Visit* 


ln(OutDatient Visits)** 


Pap Test* 


Mammoaraphv* 


PRICE91 


0.991 ^ 


0.0166 ' 


1.017' 


1.011 ' 


MFS 


0.996 ^ 


0.0026 ' 


1.004' 


1.004' 


Y93 


1.079' 


0.0509 ^ 


1.004 


1.024 


MFS*Y93 


1.001 


-0.0011 ' 


0.998 " 


0.997 ' 


OLD*Y93 


1.018 


-0.0135 


0.961 


1.071 


BLACK*Y93 


1.033 


-0.0177 


1.038 


1.083' 


MEDICAID*Y93 


0.907 ' 


-0.0504 ' 


1.040 


1.006 


DISABLED*Y93 


0.988 


-0.0158 


1.074' 


1.055'' 


RURAL*Y93 


0.999 


-0.0161 " 


1.001 


0.995 


UPOOR*Y93 


0.993 


-0.0008 


1.010 


1.021 


RPOOR*Y93 


0.992 


-0.0134 


1.016 


1.067 


UHPSA*Y93 


0.971 


-0.0245 


1.008 


0.989 


RHPSA*Y93 


0.951 


-0.0215 


0.972 


0.983 


OLD 


0.564 ' 


-0.0523 ' 


0.217' 


0.153' 


BLACK 


0.830 ' 


0.0122 


0.755 ' 


0.720 ' 


MEDICAID 


0.782 ' 


0.1068' 


0.674 ' 


0.551 ' 


DISABLED 


0.926 ' 


0.1403 ' 


0.840 ' 


0.708 ' 


RURAL 


0.986 


0.0012 


0.939 ' 


0.937 ' 


UPOOR 


0.854 ' 


-0.0037 


0.761 ' 


0.809 ' 


RPOOR 


1.074 


0.0754 ' 


0.842 ' 


0.849 ' 


UHPSA 


0.903 ' 


0.0082 


0.863 ' 


0.902 ' 


RHPSA 


0.872 ' 


-0.0531 ' 


1.038 


1.020 



AGE75 

PRIV_MED 

PCAREPOP 

SHARE65 



1.204' 



0.999 ' 
0.594 ' 
1.012 



0.1145' 

-0.0001 
-1.0041 ' 
0.0012 ' 



0.607 ' 

1.000 
17.672' 
1.014' 



0.571 ' 

0.995 ' 

13.465' 

1.012' 



NOTES: 

' Significant at the 0.05 level. 
" Significant at the 0.10 level. 

* Odds ratio from logistic regression for women in national sample. 

** Parameter estimate from logistic regression for women with an office visit. 



SOURCE: CHER analysis of Medicare Part A claims and denominator file for a sample of beneficiaries. 

3-37 



montana\finalrpt\tab3-1 9.xls\nd 



TABLE 3-20 

REGRESSION RESULTS; TIME TRENDS FOR THE PROBABILITY OF MAMMOGRAPHY FOR WOMEN 
(MAMMOGRAPHY PRICE) 



Independent 
Variable 



Mammography 

(Mammography 

Price)* 



PRICE91 
MPS 
Y93 
MFS*Y93 



1.005^ 
1.004' 
0.982 
0.996 ' 



OLD*Y93 

BLACK*Y93 

MEDICAID*Y93 

DISABLED*Y93 

RURAL*Y93 

UPOOR*Y93 

RPOOR*Y93 

UHPSA*Y93 

RHPSA*Y93 



1.070 

1 .085 ^ 

1.004 

1.055" 

1.001 

1.031 

1.069 

0.992 

0.980 



OLD 

BLACK 

MEDICAID 

DISABLED 

RURAL 

UPOOR 

RPOOR 

UHPSA 

RHPSA 



0.153^ 
0.701 ' 
0.554 ^ 
0.708 ' 
0.921 ^ 
0.826 ' 
0.850 ' 
0.921 ' 
1.039 



AGE75 



0.571 



PRIV_MED 

RADPOP 

SHARE65 



0.998 ^ 

999.000 ' 

1.014^ 



NOTES: 

° Significant at the 0.05 level. 
" Significant at the 0.10 level. 

* Odds ratio from logistic regression for women in national sample. 



3-38 



montana\finalrpt\tab3-20.xls\nd 



4.0 EPISODES OF CARE ANALYSIS 



4.1 Introduction 



The analyses presented in Chapter 3 showed relatively few utilization impacts that 
could be attributed to the Medicare Fee Schedule. However, these analyses were based on 
Medicare beneficiaries generally, and thus not able to control for health status differences that 
may affect utilization of services. By focusing on patients with specific illnesses, we may be 
better able to identify any access problems attributable to the MFS. As described earlier in 
Section 2.1.2, we selected two medical conditions for in-depth study: 

• acute myocardial infarchon (AMI); and 

• transient ischemic attack (TIA). 

Both conditions generaUy involve "high-tech" diagnostic testing, the results of which may lead 
to subsequent surgery. Many of these diagnostic tests and surgical procedures experienced 
substantial payment reductions under MFS. As a result, physicians may have been less Likely 
to provide these services, especially to vulnerable patients. At the same time, increased 
payment for hospital visits under MFS may have encouraged more intensive evaluation and 
management of pahents hospitalized with these condihons, especially on the part of specialists. 
In the sections that follow, we examine changes in utilization for patients admitted with 
either AMI or TIA in each of the three study years. AMI patients are followed for 90 days 
following admission and TIA patients for 30 days. (These follow-up periods were used in 
similar studies of patients with AMI and TIA, respectively.) Prior research has shown that 
some vulnerable groups are less likely to have a specialist in charge of their inpatient care and 
that this may partly explain lower use of diagnostic tests and procedures (Mitchell et ai, 1996b). 
Therefore, we also examine changes in the proportion of AMI patients with a cardiologist as 
their attending physician and in the proportion of TIA patients with a neurologist as their 
attending physician. The attending physician was defined as the physician submitting bills for 
routine hospital visits during the first seven days of the stay, a method developed and used in 
previous studies (Mitchell et ai, 1996a). When both a primary care physician and a specialist 
billed for hospital visits, the attending physician was classified as a specialist. Prior work with 



4-1 

montana\finalrpt\chap4.doc\nd 



stroke pahents found that treatment patterns for these "combinations" closely resembled those 
of the specialists. 

The episodes of care analysis parallels that of the Medicare population generally, with 
one exception. We did not individually examine two vulnerable groups; the very old and rural 
residents in general. First, the decision to perform tests and surgery on very old pahents with 
AMI or TIA is expected to be driven largely by the frailer health status of these patients, and 
not by relative payment changes. Second, residents of rural areas were found to generally have 
similar utilization patterns to those of urban residents (data not shown). However, we do 
evaluate MFS effects for two specific rural vulnerable groups: the rural poor and residents of 
rural shortage areas. 

4.2 Descriptive Results 

4.2.1 Time Trends in Treatment Patterns for AMI Patients 

« 
For AMI patients, we examined changes in utilization for the following services: 

• hospital visits; 

• inpatient consultations; 

• echocardiography; 

• cardiac catheterization with coronary angiography; 

• percutaneous transluminal coronary angioplasty (PTCA) 

• coronary artery bypass graft (CABG) surgery; and 

• revascularization (either PTCA or CABG). 

Because only those patients undergoing cardiac catheterization are potential candidates for 
revascularization procedures, we also analyzed: 

• revascularization, conditional on having received cardiac catheterization. 

Finally, we examined the percent of patients with a cardiologist as their attending physician. 

Rates of use for hospital visits and consultations were calculated for the inpatient stay 
only. Utilization of all tests and procedures are based on the full 90-day episode of care. 

Table 4-1 presents the utilization of these services by year for black and white AMI 
patients, respectively. Because the number of hospital visits per admission is constrained by 

4-2 

montana\ f inalrpl\ cha p4. doc\ nd 



the length of stay, we show the number of hospital visits per day. AU other services are 
expressed as the percentage of patients receiving that service. Two different tests of stahstical 
significance were performed. First, we tested whether the change from 1991 to 1993 was 
significant for each vulnerable and non-vulnerable group separately (as indicated by an "a" 
superscript). Second, for each year, we tested whether utilizahon by the vulnerable group was 
significantly different from that of their comparison group (as indicated by a "b" superscript). 

Hospital visit intensity grew significantly for both blacks and whites over the 1991-1993 
period, increasing from 0.7 visits to 0.8 per day. With a mean length of stay of 11 days, this 
represents about one-half of a visit more per stay in 1993 than in 1991. There were no 
significant changes in utilization over time for any of the other services. 

There were no significant differences between black and white AMI patients in access to 
inpatient evaluation and management services (visits and consultations) or in use of 
echocardiography (diagnostic ulh-asound of the heart). However, black AMI patients were 
significantly less likely to receive any of the three invasive procedures, compared with whites: 
cardiac catheterization, PTCA, and CABG surgery. Even after limiting the comparison to those 
patients potentially eligible for revascularization (by virtue of undergoing cardiac 
catheterization), black AMI patients still were significantly less likely to undergo surgery. 

White and black AMI patients were equally likely to have a specialist responsible for 
their inpatient care. Over one-half of all patients had a cardiologist as their attending 
physician. 

Tables 4-2 through 4-7 present similar comparisons for the other vulnerable groups: 
joint Medicaid eligibles, urban poor, rural poor, urban and rural residents of health care 
shortage areas, and the disabled, respectively. Hospital visit intensity increased for all 
vulnerable groups, although the time change did not attain statistical significance for residents 
of urban poverty and urban shortage areas. There were no other changes in service use over 
time, with two exceptions: residents of rural poverty areas (Table 4-4) and residents of rural 
shortage areas (Table 4-6) were both significantiy more likely to undergo a revascularization 
procedure in 1993, compared with 1991. 

Like blacks, AMI patients who are joint Medicaid eligible were significantly less likely 
to undergo invasive procedures (cardiac catheterization, PTCA, and CABG surgery) compared 
with non-Medicaid eUgibles (see Table 4-2). Unlike blacks, however, Medicaid-eUgible patients 
were less likely to have a cardiologist responsible for their inpatient care. Although 

4-3 

monlana\finalrpt\chap4.doc\nd 



revascularLzation rates tor joint eligibles undergoing cardiac catheterization still remain below 
those of other patients, the difference is no longer statisrically significant. 

Similarly, AMI patients from urban poverty areas (Table 4-3) also were less likely to 
undergo invasive procedures (although the CABG differential is not statistically significant). 
On the other hand, they were more likely than nonpoor patients to receive echocardiography, 
suggesting that clinical in-i^ormation obtained through this diagnostic test may influence their 
subsequent course of tieatment. Surprisingly, AMI patient from rural poverty areas (Table 4-4) 
were just as likely as nonpoor patients to undergo invasive procedures, but were significantly 
less likely to receive a consultation or echocardiography. They also were significantly less likely 
to have a cardiologist as their attending physician. 

AMI patients from urban shortage areas (Table 4-5) were less likely to receive invasive 
procedures compared with those from non-shortage areas, but only the PTCA differential was 
statistically significant. AMI patients from shortage areas (Table 4-6) resemble those from rural 
poverty areas, with significantly lower rates of consultation and echocardiography compared 
to the their reference group, but with no differences in the use of invasive procedures. Finally, 
there were no differences in use between AMI patients who originally became entitled to 
Medicare because of disability and those who did not (Table 4-7). 

4.2.2 Time Trends in Treatment Patterns for TIA Patients 

For TIA patients, we examined changes in utilization for the following services: 



• hospital visits per day; 

• consultations; 

• noninvasive cerebrovascular tests (e.g., Doppler and duplex scans); 

• CT scan of the head; 

• MRl scan of the brain; 

• cerebral angiography; and 

• carotid endarterectomy. 

We also analyzed the percent of TIA patients with a neurologist as their attending physician. 



4-4 

montana\ f inalrpt\ chap4 .doc\ nd 



Utilization of all procedures was based on the 30 day-period following hospital 
admission. Most surgeons will not perform carotid endarterectomy without first visualizing 
the carotid arteries using angiography. For this reason, we also examined: 

• carotid endarterectomy, conditional on having undergone cerebral 
angiography. 

Finally, we were interested in whether higher fees for office and hospital visits would lead to 
more comprehensive evaluation of potential candidates for anticoagulant therapy, such as 
warfarin. If so, then a higher proportion of eligible TIA patients might be managed using such 
therapy. Based on available evidence, individuals with TIA are generally considered to be 
among the most appropriate candidates for anticoagulant therapy if they have atrial fibrillation 
(EAFT Study Group, 1993). Since Medicare does not cover outpatient prescription drugs, we 
could not directly identify the use of anticoagulant drugs. Patients on these drugs should be 
monitored with prothrombin time tests, however, and we used outpatient bills for these tests 
as a proxy for warfarin use. For this analysis, we limited the sample to those TIA patients with 
a secondary diagnosis of atrial fibrillahon and who had no clinical contraindications. 
(Contraindications were defined as any secondary diagnoses that would preclude 
anticoagulant therapy, e.g., blood disorders, peptic ulcers, etc.) 

Table 4-8 presents the utilization of these services by year for black and white TIA 
patients, respectively, using the same format shown for AMI patients. UnUke AMI patients, 
visit intensity actually declined over this three-year period, significantly so for white patients. 
With an average length of stay of 6 days for white TIA patients, this implies that patients 
received about 0.66 fewer visits per admissions in 1993 than in 1991. There were no significant 
changes in utilization for any of the other services. 

While black TIA patients generally received fewer tests and procedures compared with 
white patients, these differences are not statistically significant. This is in marked contrast to 
other studies which have foimd substantial racial gaps in access to cerebrovascular services 
(e.g., Mitchell et al, 1996; Oddone et al, 1993). We suspect that this is largely due to our 
relatively small sample sizes and corresponding larger standard errors. Our sample of TIA 
patients is only one-half the size of our AMI sample. When we subset to those TIA patients 
with atrial fibrillation and without clinical contraindications, the sample size is even further 
diminished (e.g., fewer than 100 black patients per year). 

4-5 

montana\finalrpt\chap4.doc\nd 



Tables 4-9 through 4-14 present similar comparisons for the other vulnerable groups: 
joint Medicaid eligibles, urban poor, rural poor, urban and rural residents of health care 
shortage areas, and the disabled, respectively. Hospital visit intensity declined for all pahents, 
although the time change attained statistical significance only for the non-vulnerable 
comparison groups. There were no other changes in service use over time. Although not 
statistically significant, there appears to be a considerable reduction for all groups (vulnerable 
and non-vulnerable) in access to neurologists. This is puzzling, because the relative supply of 
neurologists actually increased faster over this three-year period, compared with both 
internists (the specialty most likely to treat stroke inpatients) and with physicians generally 
(Randolph et ai, 1996). 

TIA patients from rural poverty areas and rural shortage areas were significantly less 
likely to have a neurologist as their attending physician compared with other patients (Tables 
4-11 and 4-13), and less likely to receive a consultation. This presumably is due to the marked 
concentration of neurologists in urban areas (AAN, 1993), as TIA patients in urban poverty 
areas and urban shortage areas appeared to enjoy the same access to neurologists as 
comparison patients (Tables 4-10 and 4-12). Patients from rural poverty and rural shortage 
areas also were less likely to undergo certain diagnostic tests, particularly CT and MRl scans, 
but these differences were statistically significant only in 1991. 

Although many vulnerable groups displayed lower utilization levels for 
cerebrovascular tests and procedures, these differences generally were not significant. As 
discussed earlier, we suspect that our relatively small sample sizes are responsible. 

4.2.3 Changes in Payment Rates for Episode Services 

In order to capture MFS impacts, we calculated average annual allowed charges for 
each of the services and procedures of interest. These means were constipated ft-om the 
Physician/ SuppUer Procedure Summary FUes for each of the three shidy years, based on the 
charge locality in which the hospital was located. (This process, and the specific CPT 
procedure codes used, was described in detail in Section 2.3.2.1) 

Table 4-15 presents the mean aUowed charge for each service over the stiidy period. 
(Since these means were calculated for our samples of AMI and TIA patients, they do not 
necessarily represent a ta-ue national average for each of these services. Rather, they are 

4-6 

montana\finalrpt\chaf>4.doc\nd 



average payments for those services among patients admitted with ANIl or TIA.) As expected, 
payment for hospital visits increased substantially, almost 20 percent from 1991 to 1993. 
Reimbursement for consultations fell somewhat, primarily due to a one-time dislocation in 
1992 when new CPT codes for consultations were intioduced as part of the MFS. Beginning in 
1992, separate codes are used for inpatient vs. outpatient consultations, with inpatient 
consultations receiving a lower RVU weight (and hence lower Medicare payments) relative to 
those provided in outpatient settings. 

Medicare payments for aU of the AMI and TIA diagnostic tests and surgical procedures 
fell markedly. The largest reduction was observed for CABG surgery, where the average 
allowed charge was almost one-quarter lower in 1993, compared with 1991. 

4.3 Regression Results 

4.3.1 Specification and Estimation 

We tested for MFS impacts on access using the same basic model as that shown in 
Chapter 3. Regressions were estimated for a combined 1991 and 1993 sample, using the 
following specification: 

USEit = f(PRICE91jk; MFSjk; ¥93^ MFSjk*Y93i;V; V*MFSjk*Y93i;PT; HOSP) 

where USEi=utiUzation of the i-th service in year t; 

PRICE91jk=average allowed charge of the j-th service in the Medicare pricing locality k 

in 1991; 
MFSjk = percent change in the average allowed charge of the i-th service 

from 1991 to 1993; 
Y93,=l if year is 1993; 
MFSjk *93=interaction of MFSjk and Y93c 
V=vector of dummy variables for the vulnerable groups; 
V*MFSjk*Y93i= vector of interaction terms; 
PT=vector of patient characteristics; and 
HOSP=vector of hospital characteristics. 



4-7 

montana\finalrpt\chap4.doc\nd 



The PRICE91i and various MFS, variables vary according to the specific dependent variable in 
each regression. Table 4-16 displays each of the regression equations we estimated, along with 
the price variable used. 

MFS impacts are captured by the interaction terms. A significant coefficient associated 
with the MFSi*Y93 variable would indicate a change in use by the comparison group 
attributable to the MFS price change. Significant coefficients associated with the V*MFSi*Y93 
variables would indicate a change in use for the V-th vulnerable group as the result of the MFS 
price change. Seven V dummy variables and seven corresponding interaction terms are 
included to measure MFS impacts on the vulnerable groups: BLACK (black), MEDICAID (joint 
Medicaid eligible), UPOOR (urban poor), RPOOR (rural poor), UHCSA (urban shortage area), 
RHCSA (rural shortage area), and DISABLED (disabled). 

Patient characteristics expected to influence utilization include dummy variables for 
gender (MALE) and age (AGE75 for patients aged 7b to 84 and AGE85 for patients aged 85 and 
older). In addition, we calculated a Charlson Clinical Comorbidity Index for each patient based 
on secondary diagnoses. The Charlson Index is the weighted sum of selected chronic 
conditions shown to be associated with poor outcomes, such as congestive heart failure and 
chronic obstructive pulmonary disease (Charlson et ai, 1987; Deyo et ai, 1992). 

Hospital characteristics expected to affect the availability of technology include bedsize, 
teaching status, and location. Teaching status was captured by two dummy variables, MAJOR 
for hospitals with 0.25 or more residents per bed, and MINOR for those with fewer residents 
(with nonteaching hospitals the omitted category). Two dunnmy variables were used to 
characterize hospital size: LARGE for hospitals with 300 or more beds, SMALL for those with 
fewer than 100 (with medium-sized hospitals the oinitted category). Location was measured 
by a durrimy variable, HRURAT , indicating that the hospital was located in a rural area. 

This same specification was used for all regiessions for both the AMI and TIA samples. 
The hospital visit equations included one additional variable, length of stay, logged (LLOS), as 
the number of visits that can be provided are constrained by the duration of the hospital stay. 

Table 4-16 displayed all of the dependent variables for which we estimated regression 
equations. The revascularization equation was estimated twice, first for all AMI patients and 
then just for those who had undergone cardiac catheterization. Similarly, we estimated the 
carotid endarterectomy equation first for all TIA patients and then for only those who had 
received cerebral angiography. With the exception of hospital visits, the dependent variables 



4-8 

montana\finalrpt\chap4.doc\nd 



were defined as the probability that a patient would .-eceive a given service (or have a specialist 
as attending physician). Logishc regression was used to estimate these binary dependent 
variables. Since hospital visits constituted a continuous, but not normally distributed, 
dependent variable, we estimated these equations in logs using OLS. 

Means for all independent variables used in the AMI equations can be found in Table 4- 
17. Table 4-18 presents similar data for the TIA equations. 

4.3.2 Results for AMI Patients 

MF5 Impacts 

Table 4-19 presents regression results for all of the equations estimated for AMI 
patients. The numbers for the hospital visit equation represent regression coefficients; the 
numbers for all other equations are odds ratios. For categorical variables, the odds ratio 
represents the odds that the indicator group will receive the i-th service relative to the omitted 
group. In the case of continuous variables, the odds ratio can be interpreted as the change in 
the odds of receiving the procedure accompanying a one unit change in the independent 
variable. Thus, using the consultation equation in Table 4-19 as an example, a one dollar 
increase in the baseline consultation fee (PRICE91) would raise the odds of receiving a 
consultation by 0.6 percent. Interpretation is considerably more complicated in the case of 
interaction terms, e.g., MFS*Y93; for these variables, it is more meaningful to simulate the 
change in the odds by varying the levels of the continuous portion of the interaction (e.g., 

MFS). 

MFS impacts for the vulnerable patient groups are captured by the series of interaction 
terms, BLACK*MFS*Y93, etc. None of these terms are significant in the utilization equations, 
suggesting that there were no differential changes ai access over time that could be attributed 
to payment changes resulting from the fee schedule. One interaction term is significant in the 
cardiologist equation(DlSABLED*MFS*Y93), however, suggesting that increased payments for 
hospital visits raised the probabiUty that disabled patients would have a cardiologist as their 
attending physician. (Note the very low baseline odds for disabled patients.) MFS impacts for 
the non-vulnerable patient groups are caphired by the MFS*Y93 terms. AU of these are 
insignificant, except in the hospital visit equation where the coefficient is negative and 
significant (albeit only at the 10 percent level). This impUes that, in areas with a relatively 

4-9 

inontana\finalrpt\chap4.doc\nd 



greater percent increase in hospital visit payments, non-vulnerable AMI patients received 
fewer hospital visits during their stay, ceteris paribus . Although inconsistent with 
expectations, it is important to note that this is the only significant negahve MFS finding of the 
large number tested (and hence may be due to chance). 

Differenhal Use by Vulnerable Patient Groups 

While there was no indicaHon that access had worsened from 1991 to 1993 as the result 
of the MFS, the regression results in Table 4-19 indicate that, even after conh-oUing for patient 
and hospital characteristics and comorbidity, some vulnerable groups continued to utilize 
services at lower levels compared with non-vulnerable patients. There were no differences 
between vulnerable and non-vulnerable groups in the number of hospital visits or the 
probability of receiving a consultation during the inpatient stay. AMI patients who originally 
became Medicare eligible due to disability were significantly less likely to receive 
echocardiography compared with their non-disabled colleagues, but otherwise there were no 
differences in the likelihood of receiving this non-invasive diagnostic test. 

There were considerable differences in the utilization of invasive tests and surgical 
procedures, however. Black patients, those jointly eligible for Medicaid, the disabled, and the 
urban poor were all less likely to undergo cardiac catheterization. AMI patients from urban 
poverty areas, for example, were only one-half as likely to receive this invasive test (odds 
ratio=0.511), compared with patients from non-poverty areas. These same four vulnerable 
groups also were significantly less likely to undergo either PTCA or CABG surgery. Restiricted 
access to cardiac catheterization (a necessary precursor to either of these revascularization 
procedures) is one reason behind these lower surgical rates. When we limit the 
revascularization regression to those patients undergoing cardiac catheterization, the 
differences for Medicaid-eligible and urban poor patients turn insigiuficant. Nevertheless, even 
among this resh-icted sample of potential candidates for revascularization, black and disabled 
AMI patients remain significantly less likely to undergo either surgical procedure. 

Finally, both disabled and urban poor patients were significantly less likely to have a 
cardiologist as their attending physician. Access to specialists' services may help explain lower 
utilization of tests and procedures for some vulnerable groups. We explore this in more detail 
later. 



4-10 

montana\ f inalrpt\ chap4.doc\ nd 



Time Trends 

The significant coefficients associated with the time trend variable (Y93) indicate secular 
increases in hospital visit intensity, cardiac catheterization, and PTCA. The odds that an AMI 
patient would undergo PTCA in 1993, for example, were 32 percent higher than m 1991. In 
order to determine whether the utilization differenhal widened or narrowed over this time 
period for vulnerable groups, we re-estimated the equattons shown in Table 4-19, dropping all 
MPS interactions and substituting interaction terms for the vulnerable groups and the year 
1993 (e.g., BLACK*Y93, MED1CA1D*Y93, etc.). None of these interaction terms were 
significant, suggesting that, ceteris paribus, utilization for vulnerable groups changed at the 
same rate as that for non-vulnerable groups over the 1991-1993 time period. 

4.3.3 Results for TIA Patients 

MPS Impacts 

Table 4-20 presents results for aU of the regressions estimated for TIA patients. (The 
reader will note a few unusually large odds ratios in the two carotid endarterectomy 
regressions. These reflect the difficulty in estimating the odds that a relatively small patient 
group wUl receive a relatively rare procedure.) None of the vulnerable group interaction terms 
are significant, suggesting that MPS payment changes had no differential impact on any of our 
vulnerable patient groups. Similarly, the non-vulnerable interaction term (MPS*Y93) was 
insignificant in all but one equation: anticoagulant therapy. Increased office visit payments 
raised the probabUity that TIA patients would receive anticoagulant therapy, as proxied by 
outpatient prothrombin tests. An alternative explanation is that increased office visit payments 
raised the odds that patients on anticoagulant therapy would be managed more appropriately 
(i.e., be monitored with prothrombin time tests). 

Differential Use by Vulnerable Groups 

While the MPS appears to have had no adverse effect on vulnerable TIA patients, 
considerable differences in use persist. TIA patients who are joint Medicaid-eUgible received 
significantiy fewer routine hospital visits and were less likely to receive a consultation, 
compared with non-eUgible patients. Surprisingly, however, urban poor patients were 



4-11 

montana\finalrpt\ chap4.doc\ nd 



considerably more likely to receive a consult during their inpatient stay, compared with 
otherwise similar patients from non-poverty areas. 

Medicaid-eligible patients also were less likely to undergo non-invasive cerebrovascular 
testing, and less likely to receive an MRl scan. (Disabled TIA patients also were significantiy 
less likely to undergo MRI scanning.) Black TIA patients were only 60 percent as likely as 
white patients to receive cerebral angiography, an invasive diagnostic test that determines 
whether a patient is a potential candidate for carotid endarterectomy. Although the odds ratios 
associated with receiving carotid endarterectomy were very low for black patients (0.2-0.4), 
they were not statistically significant. We suspect this is due to the relatively small number of 
black TIA patients in our sample, as prior work has shown significantly lower rates of carotid 
endarterectomy for black TIA patients, even after restricting the sample to those having 
previously received cerebral angiography (Mitchell et ai, 1996b). 

Finally, both black and Medicaid-eligible TIA patients were significantly less likely to 
have a neurologist as their attending physician. In a later section, we will evaluate whether 
this may indirectly affect utilization by these two vulnerable groups. 

Time Trends 

The coefficients and odds ratios associated with the Y93 variable indicate a secular tiend 
toward fewer encounters and less testing among TIA patients. In 1993, TIA patients received 
fewer hospital visits per admission, were less likely to receive a consultation during their 
inpatient stay, and were less likely to undergo either CT scanning or cerebral angiography. A 
shift to outpatient testing can not explain the decline in use among these two diagnostic 
procedures, as utilization was counted for a 30-da\ post-admission period, regardless of 
location. The odds that a non-vulnerable TIA patient would have a neurologist as his/her 
attending physician in 1993 was only two-thirds the odds in 1991. To the extent that 
neurologists are more likely to order/ perform these tests, this could explain these patterns of 
diminishing use. We examine the role of specialty in more detail later. 

As with AMI patients, we tested whether this secular time trend was disproportionately 
larger (smaUer) for vulnerable groups, by substihiting interaction terms for 1993. None of these 
interactions was significant, implying that the declines observed for the non-vuh-.erable groups 
also took place among our vulnerable patient groups. 



4-12 

montana\fmaIrpt\chap4.doc\nd 



4.3.4 The Role of Specialty in Explaining Access to Tests and Procedures 

In the previous sections, we found lower utiiizahon rates of diagnoshc tests and 
procedures for some vulnerable groups. These differences persisted, even after adjusting for 
pahent comorbidity, and hospital characteristics that may affect the availability of these 
technologies. At the same time, we found that some vulnerable groups were less likely to 
have a relevant specialist as attendiiig physician during their hospital stay (i.e., a cardiologist in 
the case of AMI patients and a neurologist for TIA patients). To the extent that the relevant 
specialists are more knowledgeable about tests and therapies compared with primary care 
physicians, this might explain differential use for these vulnerable groups. To test this, we re- 
estimated the equations shown in Tables 4-19 and 4-20, adding a dummy variable to indicate 
whether the pahent had the relevant specialist as attending physician. If part of the vulnerable- 
nonvulnerable utiiizahon gap is due to differenhal access to specialists, then controlling for 
attending physician specialty should reduce the gap (i.e., the odds rahos associated with 
vulnerable groups should move closer to 1.0). Including physician specialty had a positive, but 
minimal, impact on the odds ratios (regression results not shown). The odds ratio associated 
with being black in the AMI revascularization equation increased from 0.573 to 0.584, for 
example, when the cardiologist dummy variable was added. 

The specialist variables themselves, however, had a powerful impact on utilization. The 
odds ratios associated with these variables are shown in Table 4-21. AMI patients with a 
cardiologist as attending physician were significantly more likely to receive echocardiography, 
cardiac catheterization, PTCA, and CABG surgery. The odds of cardiac catheterization 
increased four-fold, for example, when cardiolog.scs were responsible for managing inpatient 
care. Increased surgical utilization among AMI patients with a cardiologist appears to be 
largely attributed to the role of cardiac catheterization in making them eligible for surgery. 
When the sample is limited to those patients who received cardiac catheterization, there is no 
significant specialty impact on the odds of revascularization. 

Similarly, TIA patients with a neurologist as attending physician were significantly 
more likely to receive all forms of diagnostic cerebrovascular testing. There were no differences 
by specialty in surgical use. TIA patients with atiial fibrillation and no clinical 
contiaindications, however, were aknost twice as likely to be placed on anticoagulant therapy 
when tieated by a neurologist versus other types of physicians. 

4-13 

montana\ finalrpt\ chap4.doc\ nd 



TABLE 4-1 



TREATMENT PATTERNS FOR BLACK AND WHITE PATIENTS WITH AMI: 1991-1993 



1991 



1992 



1993 



NOTES: 

" Significant time change at the 0.05 level or better. 

^ Significantly different from white patients at the 0.05 level or better. 

SOURCE: Part A claims, Part 8 claims, and denominator file for a sample of Medicare patients admitted with AMI. 



% Change 
1991-1993 



Visits/Day 










Black 


0.72 


0.88 


0.82 


13.9% 


White 


0.73 


0.90 


0.83 


13.7% " 


Consultation 










Black 


54.4% 


55.8% 


53.2% 


-2.2% 


White 


54.0% 


54.3% 


54.0% 


0.0% 


Echocardiography 










Black 


61.1% 


60.6% 


58.7% 


-3.9% 


White 


56.3% 


55.5% 


56.0% 


-0.5% 


Cardiac Catheterization 










Black 


36.8% " 


39.8% " 


41.4% " 


12.5% 


White 


46.9% 


46.8% 


48.8% 


4.1% 


PTCA 










Black 


11.2%' 


11.9% " 


13.0% " 


16.1% 


White 


16.8% 


16.7% 


19.9% 


18.5% 


CABG 










Black 


9.0% " 


8.3% " 


9.2% " 


2.2% 


White 


14.8% 


15.4% 


14.4% 


-2.7% 


Revascularization 










Black 


19.3% " 


19.6% " 


20.8% ' 


7.8% 


White 


29.9% 


30.5% 


32.6% 


9.0% 


Revascularization 










(for patients undergoing 










cardiac catheterization) 










Black 


50.5% " 


47.8% " 


48.9% " 


-3.2% 


White 


62.4% 


63.4% 


65.2% 


4.5% 


Cardiologist as Attending Physician 










Black 


56.8% 


51.2% 


53.6% 


-5.5% 


White 


60.5% 


56,2% 


58.4% 


-3.4% 



4-14 



montanatfinalrpt\ami.xis\tat>-4-1\nd 



TABLE 4-2 

TREATMENT PATTERNS FOR MEDICAID-ELIGIBLE AND NON-ELIGIBLE PATIENTS WITH AMI: 1991-1993 



Visits/Day 

Medicaid-Eligible 
Non-Eligible 

Consultation 

Medicaid-Eligible 
Non-Eligible 

Echocardiography 
Medicaid-Eligible 
Non-Eligible 

Cardiac Catheterization 
Medicaid-Eligible 
Non-Eligible 

PTCA 

Medicaid-Eligible 
Non-Eligible 

CABG 

Medicaid-Eligible 
Non-Eligible 

Revascularization 
Medicaid-Eligible 
Non-Eligible 

Revascularization 
(for patients undergoing 
cardiac catheterization) 









% Change 


1991 


1992 


1993 


1991-1993 


0.73 


0.88 


081 


11.0% ^ 


0.73 


0.90 


083 


13.7% ' 


50.9% 


48.3% 


50.1% 


-1.6% 


54.4% 


55.4% 


54.5% 


0.2% 


55.2% 


52.1% 


52.6% 


-4.7% 


56.7% 


56.4% 


56.7% 


0.0% 


31.7% " 


32.2% " 


33.9% " 


6.9% 


48.5% 


48.5% 


50.5% 


4.1% 


10.0% '' 


11.0% " 


11.3% " 


13.0% 


17.4% 


17.3% 


20.7% 


19.0% 


8.6% " 


8.4% " 


7.9% " 


-8.1% 


15.3% 


15.9% 


15.0% 


-2.0% 


18.0% " 


18.5%" 


18.4% " 


2.2% 


30.9% 


31.5% 


33.9% 


9.7% 



Medicaid-Eligible 
Non-Eligible 


53.9% 
62.6% 


55.7% 
63.3% 


53.0% 
65.5% 


-1.7% 
4.6% 


Cardiologist as Attending Physician 
Medicaid-Eligible 
Non-Eligible 


50.9% " 
61.6% 


48.4% " 
57.0% 


50.3% " 
59.3% 


-1.2% 
-3.8% 



NOTES: 

' Significant time change at ttie 0.05 level or better. 

" Significantly different from non-eligible patients at the 0.05 level or better. 

SOURCE: Part A claims, Part B claims, and denominator file for a sample of Medicare patients admitted vinth AMI. 



4-15 



montana\finalrpt\ami.xls\tab 4-2\nd 



TABLE 4-3 

TREATMENT PATTERNS FOR URBAN POOR AND NON-POOR PATIENTS WITH AMI: 1991-1993 



1991 



1992 



NOTES: 

' Significant time change at the 0.05 level or tietter. 

" Significantly different from non-poor patients at the 0.05 level or Ijetter. 



1993 



% Change 
1991-1993 



Visits/Day 










Urban Poor 


0.74 


0.85 


0.81 


9.5% 


Non-poor 


0.73 


0.90 


0.83 


13.7%^ 


Consultation 










Urban Poor 


59.2% 


57.8% 


57.9% 


-2.2% 


Non-poor 


53.7% 


54.2% 


53.8% 


0.2% 


Echocardiography 










Urban Poor 


63.2% ^ 


63.0% ^ 


64.6% " 


2.2% 


Non-poor 


56.2% 


55.4% 


55.7% 


-0.9% 


Cardiac Catheterization 










Urban Poor 


35.8% " 


38.6% " 


37.0% " 


3.4% 


Non-poor 


46.9% 


46.8% 


49.0% 


4.5% 


PTCA 










Urban Poor 


10.9%'' 


12.9% 


12.3%" 


12.8% 


Non-poor 


16.8% 


16.6% 


19.9% 


18.5% 


CABG 










Urban Poor 


11.0% 


1 1 .2% 


9.9% 


-10.0% 


Non-poor 


14.7% 


15.1% 


14.3% 


-2.7% 


Revascularization 










Urban Poor 


20.9% " 


23.4% " 


21 .2% " 


1 .4% 


Non-poor 


29.8% 


30.2% 


32.5% 


9.1% 


Revascularization 










(for patients undergoing 










cardiac catheterization) 










Urtsan Poor 


55.2% 


58.9% 


55.0% 


-0.4% 


Non-poor 


62.1% 


62.8% 


64.7% 


4.2% 


Cardiologist as Attending Physician 










Urban Poor 


61.0% 


55.6% 


55.8% 


-8.4% 


Non-poor 


60.2% 


55.9% 


58.2% 


-3.3% 



SOURCE: Part A claims, Part B claims, and denominator file for a sample of Medicare patients admitted with AMI. 



montana\flnalrpt\ami.xls\tab-4-3\nd 



4-16 



TABLE 4-4 

TREATMENT PATTERNS FOR RURAL POOR AND NON-POOR PATIENTS WITH AMI: 1991-1993 



1991 



1992 



1993 



NOTES: 

' Significant time change at tlie 0.05 level or l)etter. 

" Significantly different from non-poor patients at the 0.05 level or better. 

SOURCE: Part A claims, Part B claims, and denominator file for a sample of Medicare patients admitted with AMI. 



% Change 
1991-1993 



Visits/Day 
Rural Poor 
Non-poor 


0.69 
0.73 


0.87 

o.no 


0.77 
0.83 


1 1 .6% ' 
13.7%' 


Consultation 
Rural Poor 
Non-poor 


39.1%" 
54.3% 


42.6% " 
54.6% 


44.1%" 
54.1% 


12.8% 
-0.4% 


Echocardiography 
Rural Poor 
Non-poor 


46.7% ^ 
56.7% 


48.4% " 
55.9% 


48.5% " 
56.3% 


3.9% 
-0.7% 


Cardiac Catheterization 
Rural Poor 
Non-poor 


42.2% 
46.4% 


45.3% 
46.4% 


46.3% 
48.4% 


9.7% 
4.3% 


PTCA 

Rural Poor 
Non-poor 


1 3.0% 
16.6% 


13.8% 
16.5% 


1 7.4% 
19.5% 


33.8% ' 
17.5% 


CABG 

Rural Poor 
Non-poor 


12.7% 
14.5% 


13.0% 
15.0% 


14.2% 
14.0% 


11.8% 
-3.4% 


Revascularization 
Rural Poor 
Non-poor 


74.0% " 
29.4% 


25.8% 
29.9% 


30.0% 
31.9% 


25.0% ' 
8.5% 


Revascularization 

(for patients undergoing 

cardiac catheterization) 

Rural Poor 

Non-poor 


55.7% 
61 .9% 


56.6% 
52.7% 


63.2% 
64.4% 


13.5% 

4.0% 


Cardiologist as Attending Physician 
Rural Poor 
Non-poor 


47.8% " 
60.5% 


51.2% 
56.0% 


51.5%" 
58.2% 


7.7% 
-3.7% 



4-17 



montana\finalrpt\ami.xls\tat)-4-4\nd 



TABLE 4-5 

TREATMENT PATTERNS FOR URBAN SHORTAGE AREA AND NON-SHORTAGE AREA PATIENTS 
WITH AMI: 1991-1993 



Visits/Day 

Urban Shortage Area 
Non-shortage Area 

Consultation 

Urban Shortage Area 
Non-shortage Area 

Echocardiography 
Urban Shortage Area 
Non-shortage Area 

Cardiac Catheterization 
Urban Shortage Area 
Non-shortage Area 

PTCA 

Urban Shortage Area 
Non-shortage Area 

CABG 

Urban Shortage Area 
Non-shortage Area 

Revascularization 
Urban Shortage Area 
Non-shortage Area 

Revascularization 
(for patients undergoing 
cardiac catheterization) 









% Change 


1991 


1992 


1993 


1991-1993 


0.75 


0.88 


0.81 


8.0% 


0.73 


0.90 


0.83 


13.7%' 


58.4% 


57.0% 


57.5% 


-1.5% 


53.9% 


54.3% 


53.9% 


0.0% 


61.8% 


60.8% 


63.3% 


2.4% 


56.4% 


55.6% 


56.0% 


-0.7% 


40.4% 


45.0% 


41.6% 


3.0% 


46.5% 


46.4% 


48.6% 


4.5% 


11.7% 


14.5% 


13.2%" 


12.8% 


16.7% 


16.5% 


19.7% 


18.0% 


13.0% 


14.8% 


10.9% 


-16.2% 


14.5% 


14.9% 


14.1% 


-2.8% 


23.0% " 


27.7% 


23.2% ^ 


0.9% 


29.5% 


29.9% 


32.1% 


8.8% 



Urtsan Shortage Area 
Non-shortage Area 


54.0% 
62.0% 


50.2% 
62.7% 


54.4% 
64.6% 


0.7% 
4.2% 


Cardiologist as Attending Physician 
Urban Shortage Area 
Non-shortage Area 


62.8% 
60.2% 


56.0% 
55.9% 


55.6% 
58.2% 


-11.5% 
-3.3% 



NOTES: 
3 Significant time change at the 0.05 level or better. 
*> Significantly different from non-shortage area patients at the 0.05 level or better. 

SOURCE: Part A claims, Part B claims, and denominator file for a sample of Medicare patients admitted wnth AMI. 



montana\finalrpt\ami.xls\tab-4-5\nd 



TABLE 4-6 

TREATMENT PATTERNS FOR RURAL SHORTAGE AREA AtJD NON-SHORTAGE AREA PATIENTS 
WITH AMI: 1991-1993 



Visits/Day 

Rural Shortage Area 
Non-shortage Area 

Consultation 

Rural Shortage Area 
Non-shortage Area 

Echocardiography 
Rural Shortage Area 
Non-shortage Area 

Cardiac Catheterization 
Rural Shortage Area 
Non-shortage Area 

PTCA 

Rural Shortage Area 
Non-shortage Area 

CABG 

Rural Shortage Area 
Non-shortage Area 

Revascularization 
Rural Shortage Area 
Non-shortage Area 









% Change 


1991 


1992 


1993 


1991-1993 


0.65" 


0.83" 


0.76" 


16.9% ^ 


0.74 


0.90 


0.83 


12.2%^ 


41.1%" 


36.9% " 


40.3% " 


-1 .9% 


54.3% 


54.8% 


54.3% 


0.0% 


43.0% " 


46.7% " 


47.4% " 


10.2% 


56.9% 


56.0% 


56.3% 


-1.1% 


43.4% 


45.8% 


48.7% 


12.2% 


46.4% 


46.4% 


48.3% 


4.1% 


13.7% 


14.7% 


19.1% 


39.4% 


16.6% 


16.5% 


19.5% 


17.5% 


14.3% 


13.8% 


16.8% 


17.5% 


14.5% 


15.0% 


14.0% 


-3.4% 


26.9% 


27.7% 


34.2% 


27.1%' 


29.4% 


29.9% 


31 .8% 


8.2% 



Revascularization 

(for patients undergoing 

cardiac catheterization) 

Rural Shortage Area 

Non-shortage Area 

Cardiologist as Attending Physician 
Rural Shortage Area 
Non-shortage Area 



60.9% 


58.4% 


68.7% 


12.8% 


61.9% 


62.7% 


64.3% 


3.9% 


47.4% " 


50.3% 


52.1% 


10.1% 


60.6% 


56.0% 


58.3% 


-3.8% 



NOTES: 
* Significant time change at the 0.05 level or t)etter. 
" Significantly different from non-shortage area patients at the 05 level or better. 

SOURCE: Part A claims, Part B claims, and denominator file for a sample of Medicare patients admitted with AMI. 



4-19 



montana\finalrpt\ami.xls\tab-4-6\nd 



TABLE 4-7 

TREATMENT PATTERNS FOR DISABLED AND NON-DISABLED PATIENTS WITH AMI: 1991-1993 



Visits/Day 
Disabled 
Non-disabled 

Consultation 
Disabled 
Non-disabled 

Echocardiography 
Disabled 
Non-disabled 

Cardiac Catheterization 
Disabled 
Non-disabled 

PTCA 
Disabled 
Non-disabled 

CABG 
Disabled 
Non-disabled 

Revascularization 
Disabled 
Non-disabled 

Revascularization 

(for patients undergoing 

cardiac catheterization) 

Disabled 

Non-disabled 

Cardiologist as Attending Physician 
Disabled 
Non-disabled 









% Change 


1991 


1992 


1993 


1991-1993 


0.70 


0.89 


0.83 


18.6%^ 


0.75 


0.91 


0.84 


12.0% ^ 


53.5% 


53.0% 


53.3% 


-0.4% 


54.1% 


54.7% 


54.1% 


0.0% 


53.3% 


55.2% 


54.3% 


1.9% 


57.1% 


55.9% 


56.5% 


-1.1% 


50.0% 


53.7% ^ 


54.3% 


8.6% 


45.7% 


45.0% 


47.3% 


3.5% 


16.0% 


18.1% 


19.8% 


23.8% 


16.6% 


16.1% 


19.4% 


16.9% 


14.6% 


15.4% 


15.1% 


3.4% 


14.5% 


14.8% 


13.9% 


-4.1% 


29.0% 


31.3% 


32.6% 


12.4% 


29.4% 


29.5% 


31.7% 


7.8% 



55.9% 


56.5% 


58.6% 


4.8% 


63.1% 


64.0% 


65.6% 


4.0% 


60.6% 


58.6% 


61 .7% 


1 .9% 


60.2% 


55.4% 


57.5% 


-4.6% 



NOTES: 
' Significant different from ami disabled patients at ttie 0.05 level or t>etter. 
' Significantly different from non-disabled patients at the 0.05 level or better. 

SOURCE: Part A claims, Part B claims, and denominator file for a sample of Medicare patients admitted with AMI. 



** 20 montana\finalrpt\ami.xls\tab-4-7\nd 



TABLE 4-8 

TREATMENT PATTERNS FOR BU\CK AND WHITE PATIENTS WITH TIA: 1991-1993 









% 


Change 


1991 


1992 


1993 


1991-1993 


0.84 


0.88 


0.77 




-8.3% 


0.87 


0.89 


0.76 




-12.6% " 


48.2% 


47.6% 


44.6% 




-7.5% 


49.9% 


47.0% 


46.3% 




-7.2% 



Visits/Day 
Black 
White 

Consultation 
Black 
White 

Non-Invasive Cerebro- 
vascular Tests 

Black 

White 

CT Scan, Head 
Black 
White 

MRI Scan, Brain 
Black 
White 

Cerebral Angiography 
Black 
White 

Carotid Endarterectomy 
Black 
White 

Carotid Endarterectomy 

(for patients undergoing 

cerebral angiography) 

Black 8.7% 13.6% 24.1% 177.0% 

White 22.8% 28.6% 27.5% 20.6% 

Anticoagulant Therapy 
(for patients with atrial 
fibrillation only) 

Black 

White 

Neurologist as Attending Physician 
Black 
White 



NOTES: 

' Significant time change at the 0.05 level or better. 

" Significantly different from white patients at the 0.05 level or better. 

SOURCE: Part A claims, Part B claims, and denominator file for a sample of Medicare patients admitted with TIA. 

4-21 montana\finalrpt\tia.xls\TAB-4-8\nd 



42.5% 


47,9% 


46.4% 


9.2% 


48.0% 


50.5% 


5? 5% 


5.4% 


76.3% 


71.6% 


71.1% 


-6.8% 


74.5% 


66.4% 


69.1% 


-7.2% 


9.5% 


11.0% 


11.6% 


22.1% 


12.5% 


12.9% 


12.8% 


2.4% 


4.3% 


3.4% 


3.2% 


-25.6% 


7.7% 


7.0% 


5.2% 


-32.5% 


0.4% 


1.0% 


0.9% 


125.0% 


2.2% 


2.7% 


1.8% 


-18.2% 



20.7% 


23.0% 


24.3% 


17.4% 


34.4% 


34.2% 


32.2% 


-6.4% 


26.2% 


22.1% 


21.3% 


-18.7% 


30.1% 


22.5% 


22.9% 


-24.0% 



TABLE 4-9 

TREATMENT PATTERNS FOR MEDICAID-ELIGIBLE AND NON-ELIGIBLE PATIENTS WITH TIA: 199 i-1993 



Visits/Day 

Medicaid eligible 
Non-Medlcaid eligible 

Consultation 

Medicaid eligible 
Non-Medicaid eligible 

Non-Invasive Cerebro- 
vascular Tests 

Medicaid eli^^ible 
Non-Medicaid eligible 

CT Scan, Head 

Medicaid eligible 
Non-Medicaid eligible 

MRI Scan, Brain 
Medicaid eligible 
Non-Medicaid eligible 

Cerebral Angiography 
Medicaid eligible 
Non-Medicaid eligible 

Carotid Endarterectomy 
Medicaid eligible 
Non-Medicaid eligible 

Carotid Endarterectomy 
(for patients undergoing 
cerebral angiography) 
Medicaid eligible 
Non-Medicaid eligible 

Anticoagulant Therapy 
(for patients with atrial 
fibrillation only) 









% 


Change 


1991 


1992 


1993 


1991-1993 


0.83 


0.88 


0.77 




-7.2% 


0.86 


0.89 


0.76 




-11.6% ' 


42.3% 


39.6% 


39.1% 




-7.6% 


51.2% 


48.5% 


47.6% 




-7.0% 



37.4% " 


41 0% ' 


41.9% 


12.0% 


49.5% 


52.1% 


51.9% 


4.8% 


73.7% 


66.0% 


68.3% 


-7.3% 


74.8% 


67.0% 


69.4% 


-7.2% 


7.2% " 


8.6% 


7.4% 


2.8% 


13.2% 


13 5% 


13.8% 


4.5% 


4.5% 


3.3% 


4.1% 


-8.9% 


7.9% 


7.4% 


5 3% 


-32.9% 


1.0% 


08% 


1.0% 


0.0% 


2.2% 


2.9% 


1.9% 


-13.6% 



13.7% 
23.0% 



17.9% 
28.8% 



24.6% 
27.7% 



NOTES: 

' Significant tjine change at the 0.05 level or Ijetter. 

"■ Significantly different from non-Medicaid-eligible patients at the 0.05 level or Ijetter. 

SOURCE: Part A claims, Part B claims, and denominator file for a sample of Medicare patients admitted with TIA. 

4-22 



79.6% 
20.4% 



Medicaid eligible 
Non-Medicaid eligible 


24.9% 
35.4% 


24.4% 
35.2% 


24.0% 
33.1% 


-3.6% 
-6.5% 


Neurologist as Attending Physician 
Medicaid eligible 
Non-Medicaid eligible 


22.2% ' 
31.3% 


17.8% 
23.3% 


16.0% 
24.2% 


-27.9% 
-22.8% 



montana\finalrpt\tia.xls\TAB-4-9\nd 



TABLE 4-10 

TREATMENT PATTERr>;S FOR URBAN POOR AND NON-POOR PATIENTS WITH TIA. 1991-1993 



Visits/Day 

Urban poor 
Non-poor 

Consultation 
Urban poor 
Non-poor 

Non-Invasive Cerebro- 
vascular Tests 

Urban poor 

Non-poor 

CT Scan, Head 
Urban poor 
Non-poor 

MRI Scan, Brain 
Urban poor 
Non-poor 

Cerebral Angiography 
Urban poor 
Non-poor 

Carotid Endarterectomy 
Urban poor 
Non-poor 

Carotid Endarterectomy 
(for patients undergoing 
cerebral angiography) 

Urban poor 

Non-poor 

Anticoagulant Therapy 
(for patients with atrial 
fibrillation only) 

Urban poor 

Non-poor 

Neurologist as Attending Physician 
Urban poor 
Non-poor 









% Change 


1991 


1992 


1993 


1991-1993 


0.87 


0.85 


0.81 


-6.9% 


0.86 


0.89 


0.76 


-11.6% ^ 


65.0% " 


59.2% " 


58.5% " 


-10.0% 


48.7% 


46.3% 


45.3% 


-7.0% 



45.7% 


48.5% 


50.9% 


11.4% 


47.6% 


50.4% 


50.1% 


5.3% 


76.4% 


70.7% 


74.8% 


-2 1% 


74.5% 


66.6% 


68.9% 


-7.5% 


12.9% 


10.9% 


11.7% 


-9.3% 


12.2% 


12.8% 


12.7% 


4.1% 


5.0% 


2.7% 


2.4% 


-52.0% 


7.5% 


7.0% 


5.2% 


-30.7% 


0.5% 


1.4% 


1.0% 


100.0% 


2.1% 


2.6% 


1.8% 


-14.3% 



10.4% 
22.6% 



16.1% 
28.3% 



31.6% 
27.2% 



203.8% 
20.4% 



22.0% 


24.1% 


30.5% 


38.6% 


34,3% 


34.4% 


31.9% 


-7.0% 


36.2% 


24.7% 


24.2% 


-32.9% 


29.4% 


22.3% 


22.6% 


-22.8% 



NOTES: 

' Significant time change at the 0.05 level or lietter. 

•i Significantly different from non-poor patients at the 0.05 level or t>etter. 

SOURCE: Part A claims. Part B claims, and denominator file for a sample of Medicare patients admitted with TIA. 



montana\finalrpt\tia.xls\TAB-4-1 0\nd 



4-23 



TABLE 4-11 

TREATMENT PATTERNS FOR RURAL POOR AND NON-POOR PATIENTS WITH TIA: 1991-1993 



Visits/Day 

Rural poor 
Non-poor 

Consultation 
Rural poor 
Non-poor 

Non-Invasive Cerebro- 
vascular Tests 

Rural poor 

Non-poor 

CT Scan, Head 
Rural poor 
Non-poor 

MR! Scan, Brain 
Rural poor 
Non-poor 

Cerebral Angiography 
Rural poor 
Non-poor 

Carotid Endarterectomy 
Rural poor 
Non-poor 

Carotid Endarterectomy 
(for patients undergoing 
cerebral angiography) 

Rural poor 

Non-poor 









% Change 


1991 


1992 


1993 


1991-1993 


0.82 


0.9C 


0.74 


-9.8% 


0.86 


0.90 


0,77 


-10.5% ' 


26.8% " 


24.3% " 


26.2% " 


-2.2% 


50.2% 


47.6% 


46.6% 


-7.2% 



40.5% 


42.5% " 


46.9% 


15.8% 


47.6% 


50.5% 


50.3% 


5.7% 


67.7% " 


64.9% 


65.9% 


-2.7% 


74.8% 


66.9% 


69.3% 


-7.4% 


7.5% " 


9.3% 


10.3% 


37.3% 


12.3% 


12.8% 


12 7% 


3.3% 


8.5% 


6.9% 


5.7% 


-32.9% 


7.3% 


6.8% 


5.0% 


-31.5% 


2.5% 


1.4% 


1.3% 


-48.0% 


2.0% 


2.6% 


1.7% 


-15.0% 



25.5% 
22.0% 



18.5% 
28.2% 



21.7% 
27.4% 



-14.9% 
24.5% 



Anticoagulant Therapy 










(for patients with atrial 










fibrillation only) 










Rural poor 


31.8% 


22.5% 


34.6% 


8.8% 


Non-poor 


33.8% 


34.0% 


32.1% 


-5.0% 


Neurologist as Attending Physician 


13.8% " 


13.3% 


13.1%" 


-5,0% 


Rural poor 


30.1% 


22.6% 


23.0% 


-23.8% 


Non-poor 











NOTES: 

• Significant time change at the 0.05 level or better 

' Significantly different from non-poor patients at the 05 level or tietter 

SOURCE: Part A claims, Part B claims, and denominator file for a sample of Medicare patients admitted with TIA. 



4-24 



montana\finalrpt\tia.xls\TAB-4-1 1 \nd 



TABLE 4-12 

TREATMENT PATTERNS FOR URBAN SHORTAGE AREA AND NON-SHORTAGE AREA PATIENTS 
WITHTIA: 1991-1993 



Visits/Day 

Urban Shortage Area 
Non-shortage Area 



1991 

0.85 
0.86 



1992 

0.85 
0.89 



1993 

0.75 
0.77 



% Change 
1991-1993 

-11.8% 
-10.5% " 



Consultation 

Urban Shortage Area 
Non-shortage Area 



60.4% " 
49.3% 



53.8% 
46.8% 



55.1% 
45.8% 



-8.8% 
-7.1% 



Non-Invasive Cerebro- 
vascular Tests 

Urban Shortage Area 
Non-shortage Area 

CT Scan, Head 

Urban Shortage Area 
Non-shortage Area 

MRI Scan, Brain 

Urban Shortage Area 
Non-shortage Area 

Cerebral Angiography 
Urban Shortage Area 
Non-shortage Area 

Carotid Endarterectomy 
Urban Shortage Area 
Non-shortage Area 



47.2% 


44.3% 


49.7% 


5.3% 


47.5% 


50.5% 


50.2% 


5.7% 


77.3% 


73.0% 


73.0% 


-5.6% 


74.5% 


66.6% 


69.1% 


-7.2% 


9.8% 


10.4% 


12.0% 


22.4% 


12.3% 


12.8% 


12.7% 


3.3% 


4.9% 


3.9% 


4.6% 


-6.1% 


7.5% 


6.8% 


5.1% 


-32.0% 


1.5% 


8% 


0.6% 


-60.0% 


2.0% 


2.6% 


1.7% 


-15.0% 



Carotid Endarterectomy 
(for patients undergoing 
cerebral angiography) 
Urban Shortage Area 
Non-shortage Area 



23.3% 
22.0% 



22.5% 
28.1% 



14.5% 
27.7% 



-37.8% 
25.9% 



Anticoagulant Therapy 
(for patients v>^ith atrial 
fibrillation only) 



Urban Shortage Area 


23.2% 


31.3% 


33.6% 


44.8% 


Non-shortage Area 


34.0% 


33.9% 


31.8% 


-6.5% 


Neurologist as Attending Physician 










Urban Shortage Area 


30.6% 


19.6% 


24.0% 


-21.5% 


Non-shortage Area 


29.7% 


22.5% 


22.7% 


-23.7% 



NOTES: 

» Significant time change at the 0.05 level or t>etter. 

"> Significantly different from non-shortage area patients at the 0.05 level or tietter. 

SOURCE: Part A claims, Part B claims, and denominator file for a sample of Medicare patients admitted with TIA. 



4-25 



montana\fin3lrpt\tia.xls\TAB-4-1 2\nd 



TABLE 4-13 

TREATMENT PATTERNS FOR RURAL SHORTAGE AND NON-SHORTAGE AREA PATIENTS 
WITHTIA: 1991-1993 



Visits/Day 

Rural shortage area 
Non-shortage area 

Consultation 

Rural shortage area 
Non-shortage area 









% Change 


1991 


1992 


1993 


1991-1993 


0.77" 


0.83 


0.71 


-7.8% 


0.86 


0.89 


0.77 


-10.5% ' 


33.1%" 


31.5%" 


26.6% " 


-19.6% 


50.1% 


47.4% 


46.5% 


-7.2% 



Non-Invasive Cerebro- 
vascular Tests 

Rural shortage area 
Non-shortage area 

CT Scan, Head 

Rural shortage area 
Non-shortage area 

MRI Scan, Brain 

Rural shortage area 
Non-shortage area 

Cerebral Angiography 
Rural shortage area 
Non-shortage area 

Carotid Endarterectomy 
Rural shortage area 
Non-shortage area 



41.1% 


45.1% 


44.7% 


8.8% 


47.6% 


50.4% 


50.3% 


5.7% 


65.7% " 


62.0% 


63.5% 


-3.3% 


74.8% 


67.0% 


69.4% 


-7.2% 


8.8% 


13.1% 


10.8% 


22.7% 


12.3% 


12.7% 


12.7% 


3.3% 


7.6% 


4.8% 


5.3% 


-30.3% 


7.4% 


6.8% 


5.1% 


-31.1% 


4.4% 


1.3% 


1.6% 


-63.6% 


2.0% 


2.5% 


1.7% 


-15.0% 



Carotid Endarterectomy 
(for patients undergoing 
cerebral angiography) 
Rural shortage area 
Non-shortage area 



51.4% 
21.4% 



22.1% 
28.1% 



28.9% 
27.3% 



-43.8% 
27.6% 



Anticoagulant Therapy 
(for patients with atrial 
fibrillation only) 

Rural shortage area 

Non-shortage area 

Neurologist as Attending Physician 
Rural shortage area 
Non-shortage area 



22.6% 


46.8% 


35.3% 


56.2% 


33.9% 


33.5% 


31.8% 


-6.2% 


15.1%" 


11.7%" 


13.4% " 


-11.5% 


30.1% 


22.7% 


22.9% 


-23.8% 



NOTES: 

■ Significant time change at ttie 0.05 level or taetter. 

>> Significantly different from non-shortage area patients at the 05 level or better 

SOURCE: Part A claims. Part B claims, and denominator file for a sample of Medicare patients admitted with TIA 



montanaVinalrptUia xls\TAB-4-1 3\nd 



TABLE 4-14 

TREATMENT PATTERNS FOR DISABLED AND NON-DISABLED PATIENTS WITH TIA: 1991-1993 



Visits/Day 
Disabled 
Non-Disabled 

Consultation 
Disabled 
Non-Disabled 









% Change 


1991 


1992 


1993 


1991-1993 


0.86 


0.90 


0.76 


-11.6% 


0.86 


0.89 


0.77 


-10.5% ' 


52.5% 


50.7% 


50.4% 


-4.0% 


49.3% 


46.6% 


45.5% 


-7.7% 



Non-Invasive Cerebro- 
vascular Tests 
Disabled 
Non-Disabled 

CT Scan, Head 
Disabled 
Non-Disabled 

MRI Scan, Brain 
Disabled 
Non-Disabled 

Cerebral Angiography 
Disabled 
Non-Disabled 

Carotid Endarterectomy 
Disabled 
Non-Disabled 



47.7% 


51.7% 


52.9% 


10.9% 


47.4% 


50.1% 


49.8% 


5.1% 


73.9% 


66.7% 


71 6% 


-3.1% 


74.7% 


66.9% 


68.9% 


-7.8% 


13.4% 


13.5% 


14.2% 


6.0% 


12.0% 


12.6% 


12.4% 


3.3% 


9.2% 


7.2% 


7.3% 


-20.7% 


7.1% 


6.6% 


4.7% 


-33.8% 


2.1% 


2.1% 


2.2% 


4.8% 


2.0% 


2.6% 


1.6% 


-20.0% 



Carotid Endarterectomy 

(for patients undergoing 

cerebral angiography) 

Disabled 

Non-Disabled 



16.2% 
23.1% 



20.3% 
29.1% 



23.9% 
28.1% 



47.5% 
21.6% 



Anticoagulant Therapy 










(for patients with atrial 










fibrillation only) 










Disabled 


37.5% 


29.9% 


41.8% 


11.5% 


Non-Disabled 


33.2% 


34.2% 


30.8% 


-7.2% 


Neurologist as Attending Physician 










Disabled 


32.7% 


25.8% 


26.0% 


-20.6% 


Non-Disabled 


29.4% 


22.0% 


22.3% 


-24.2% 



NOTES: 

• Significant time change at the 0.05 level or Ijetter. 

' Significantly dilTefent from non-disabled patients at the 05 level or tsetter 

SOURCE: Part A claims. Part B claims, and denominator tile for a sample of Medicare patients admitted with TIA. 



4-27 



montana\finalrpt\tia xls\TAB-4-1 4\nd 



TABLE 4-15 

CHANGES IN MEDICARE ALLOWED CHARGES, 1991-1993 











% Change 




1991 


1992 


1993 


1991-1993 


Evaluation & Manaaement 










Hospital Visit 


$35.93 


$40.62 


$42.92 


19.5 % 


Consultation 


82.64 


74.47 


78.88 


-4.5 


AMI Tests/Procedures 










Echocardiography 


107 


101 


93 


-13.1 


Cardiac catheterization 


722 


637 


567 


-21.5 


PTCA 


1,396 


1,220 


1,137 


-18.6 


CABG 


2,968 


2,548 


2,254 


-24.1 


TIA Tests/Procedures 










Non-invasive cerebrovascular tests 


113 


91 


92 


-18.6 


CT, head* 


64 


56 


54 


-15.6 


MRI, brain* 


101 


87 


83 


-17.8 


Cerebral angiography 


104 


90 


87 


-16.3 


Carotid endarterectomy 


1,286 


1,113 


1,121 


-12.8 



•Interpretation and report only. 

SOURCE: Physician/Supplier Procedure Summary Files 1991-1993. 



4-28 



montana\finalrpt\tia xls\tab-4-1 5\nd 



TABLE 4-16 

PRICE VARIABLES USED IN EPISODE OF CARE REGRESSIONS 



Dependent Variable 



Price Variable 



Hospital visits 
Consultation 



Hospital visits 
Inpatient consultations 



AMI: 



EchocanJiography 
Cardiac catheterization 

PTCA 

CABG surgery 

Revascularization 

Cardiologist as attending physician 



EchocanJiography 

Left/combined cardiac catheterization 
with coronary angiography 
PTCA 

CABG surgery 

Locality average of PTCA and CABG 
Hospital visits 



TIA: 



Non-invasive cerebrovascular tests 
CT scan, head 

MRI scan, brain 

Cerebral angiography 
Carotid endarterectomy 
Anticoagulant therapy 
Neurologist as attending physician 



Non-invasive cerebrovascular tests 
CT scan, head, interpretation and report 

only 
MRI scan, brain, interpretation and 

report only 

Cerebral angiography 
Carotid endarterectomy 
Office visits 
Hospital visits 



4-29 



Montana\finalrpt\tab4-1 6.doc\nd 



TABLE 4-17 

AMI WEIGHTED MEANS 



Revascularization 

(for patients Cardiologist 



Independent 


Hospital 


Inpatient 




Cardiac 




CABG 




undergoing 


as Attending 


Variables 


Visits 


Consultation 


^chocardioqraphy 


Catheterization 


PTCA 


Suraery 


Revascularization 


cardiac cath) 


Ptivsician 


PRICE91 


36.015 


82.958 


106.843 


721 .068 


1399.270 


2976.890 


2188.080 


2191.190 


36.015 


MFS 


0.213 


-0.031 


-0.103 


-0.206 


-0.180 


-0.227 


-0.218 


-0.214 


0.213 


Y93 


0.506 


0.506 


0.506 


0.506 


0.506 


0.506 


0.506 


0.517 


0.506 


MFS'Y93 


0.107 


-0.017 


-0.052 


-0.104 


-0.092 


-0.116 


-0.111 


-0.112 


0107 


BUCK*MFS*Y93 


0.059 


0.059 


0.059 


0.059 


0.059 


0.059 


0.059 


0.049 


0.059 


MEDICAID*MFS*Y93 


0.128 


0.128 


0.128 


0.128 


0.128 


0.128 


0.128 


0.089 


0.128 


DISABLED*MFS*Y93 


0.156 


0.156 


0.156 


0.156 


0.156 


0.156 


0.156 


172 


0.156 


UPOOR*MFS*Y93 


0.052 


0.052 


0.052 


0.052 


0.052 


0.052 


0.052 


0.040 


0.052 


RPOOR*MFS-Y93 


0.017 


0.017 


0.017 


0.017 


0.017 


0.017 


0.017 


0016 


0.017 


UHPSA'MFS*Y93 


0.029 


0.029 


0.029 


0.029 


0.029 


0.029 


0.029 


0.025 


0.029 


RHPSA*MFS*Y93 


0.022 


0.022 


0.022 


0.022 


0.022 


0.022 


0.022 


0.021 


0.022 


BLACK 


0.006 


-0.001 


-0.004 


-0.006 


-0.006 


-0.007 


-0.007 


-0,00b 


006 


MEDICAID 


0.015 


-0.002 


-0.007 


-0.014 


-0.012 


-0.014 


-0.014 


-O.Ong 


0015 


DISABLED 


0.017 


-0.002 


-0.009 


-0.016 


-0 014 


-0.018 


-0.017 


-0 019 


0.017 


UPOOR 


0.004 


-0.002 


-0.002 


-0.005 


-0.005 


-0.006 


-0.006 


-0 004 


0004 


RPOOR 


0.002 


0.000 


-0.001 


-0.002 


-0.002 


-0.002 


-0.002 


-0 002 


0.002 


UHPSA 


0.003 


-0.001 


-0.001 


-0.003 


-0.002 


-0.003 


-0.003 


-0.003 


0,003 


RHPSA 


0.003 


0.000 


-0.001 


-0.002 


-0.002 


-0.003 


-0.002 


-0.002 


0,003 


MALE 


0.526 


0.526 


0.526 


0.526 


0.526 


0.526 


0.526 


0.589 


0.526 


AGE75 


0.365 


0.365 


0.365 


0.365 


0.365 


0.365 


0.365 


0288 


0.365 


AGE85 


0.119 


0.119 


0.119 


0.119 


0.119 


0.119 


0.119 


0.023 


0.119 


CHARLSON 


0.909 


0.909 


0.909 


0.909 


0.909 


0.909 


0.909 


0.706 


909 


MAJOR 


0.103 


0.103 


0.103 


0.103 


0.103 


0.103 


0.103 


138 


103 


MINOR 


0.400 


0.400 


0.400 


0.400 


0.400 


0.400 


0.400 


0,480 


400 


LARGE 


0.471 


0.471 


0.471 


0.471 


0.471 


0.471 


0.471 


0612 


0.471 


SMALL 


0.115 


0.115 


0.115 


0.115 


0.115 


0.115 


0.115 


0.043 


0.115 


HRURAL 


0.175 


0.175 


0.175 


0.175 


0.175 


0.175 


0.175 


0093 


0.175 


LLOS 


2.221 



















SOURCE: 



.nonlana\finalipt\t,ili'l i ? /l>,>riij 



TABLE 4-18 






















TIA WEIGHTED MEANS 






































Carotid 






















Endarterectomy 


Anticoagulant 




















(for patients 


Therapy 










Non-Invasive 










undergoing 


(for patients 


Neurologist 


Independent 


Hospital 


Inpatient 


erebrovascular 


CT Scan, 


MRI Scan, 


Cerebral 


Carotid 


cerebral 


with atrial 


as Attending 


Variables 


Visits 


Consultation 


Tests 


Head 


Brain 


Anaioaraohv 


Endarterectomv 


anaioaraohvl 


flbrilationl 


Phvsician 




35.896 


62.965 


114.025 


63.906 


101.714 


104.402 


1291.950 


1291.950 


29.342 


35 896 


PRICE91 


0.215 


-0.036 


-0.177 


-0.175 


-0.118 


-0.160 


-0.161 


-0.163 


0.106 


0.215 


MFS 


0.482 


0.482 


0.482 


0.482 


0.482 


0.482 


0.482 


0.390 


0.540 


0.482 


Y93 


0.102 


-0.018 


-0.086 


-0.085 


-0.058 


-0.077 


-0.078 


-0.064 


0.053 


0.102 


MFS-Y93 


0.398 


0.398 


0.398 


0.398 


0.398 


0.398 


0.398 


0.553 


0.418 


0.398 


BLACK'MFS*Y93 


0.009 


-0.002 


-0.009 


-0.008 


-0.004 


-0 007 


-0.007 


-0.004 


0.002 


009 


MEDICAID-MFS"Y93 


0.018 


-0.003 


-0.018 


-0.015 


-0.008 


-0.013 


-0.014 


-0.009 


0.009 


018 


DISABLED*MFS-Y93 


0.014 


-0.002 


-0.012 


-0.011 


-0.007 


-0.010 


-0.010 


-0.012 


0.007 


0.014 


UPOOR-MFS'Y93 


0.005 


-0.002 


-0.004 


-0.005 


-0.004 


-0.004 


-0.005 


-0.002 


0.002 


0.005 


RPOOR*MFS-Y93 


0003 


0.000 


-0.003 


-0.002 


-0.001 


-0.001 


-0 002 


-0.002 


0.002 


003 


UHPSA"MFS'Y93 


0.003 


-0.00 : 


-0.003 


-0.003 


-0.002 


-0.003 


-0.003 


-0.002 


0.001 


0.003 


RHPSA*MFS-Y93 


0.003 


0.000 


-0.002 


-0.002 


-0.001 


-0.001 


-0.002 


-0 001 


0.0O2 


0003 


BLACK 


0.170 


0.170 


0.170 


0.170 


0.170 


0.170 


0.170 


0.118 


0.146 


170 


MEDICAID 


0.127 


0.127 


0.127 


0.127 


0.127 


127 


0.127 


0.168 


0.107 


127 


DISABLED 


0.061 


0.061 


0.061 


0.061 


0.061 


0.061 


0.061 


0.038 


0.049 


061 


UPOOR 


0.023 


0.023 


0.023 


0.023 


0.023 


0.023 


0023 


0026 


0.021 


0.023 


RPOOR 


0.035 


0.035 


0.035 


0.035 


0.035 


0.035 


0.035 


0.027 


0.027 


0035 


UHPSA 


0.021 


0.021 


0.021 


0.021 


0.021 


0.021 


0.021 


0.022 


0.022 


021 


RHPSA 


0.059 


0.059 


0.059 


0.059 


0.059 


0.059 


0.059 


0.074 


0.061 


0,059 


MALE 


0.415 


0.415 


0.415 


0.415 


0.415 


0.415 


0.415 


0398 


0,422 


0,415 


AGE75 


0.202 


0.202 


0.202 


0.202 


0.202 


0202 


0.202 


054 


258 


0,202 


AGE85 


0.090 


0.090 


0.090 


0.090 


0.C90 


0090 


0.090 


0.055 


0.044 


090 


CHARLSON 


0.230 


0.230 


0.230 


0.230 


0.230 


0.230 


0.230 


0.177 


0.234 


230 


MAJOR 


0.323 


0.323 


0.323 


0.323 


0.323 


0.323 


0.323 


0.408 


354 


0,323 


MINOR 


0.338 


0.338 


0.338 


0.338 


0.338 


0.338 


0.338 


0,475 


322 


0,338 


LARGE 


0.178 


0.178 


0.178 


0.178 


0.178 


178 


0.178 


0094 


0.173 


178 


SMALL 


0.626 


0.626 


0.626 


0.626 


0.626 


0.626 


0.626 


0.520 


0577 


0,626 



HRURAL 



LLOS 



1.687 



SOURCE: 



iriorU.:iria>tmjlrptMjM l.'.l<l',,r, I 



TABLE 4-19 



REGRESSION RESULTS: MFS IMPACTS ON AMI PATIENTS 



Independent 
Variable 

PRICE91 
MFS 
Y93 
MFS*Y93 

BLACK*MFS*Y93 

MEDICAID*MFS*Y93 

DiSABLED*MFS*Y93 

UPOOR*MFS*Y93 

RPOOR*MFS*Y93 

UHCSA*MFS*Y93 

RHCSA*MFS*Y93 

BLACK 

MEDICAID 

DISABLED 

UPOOR 

RPOOR 

UHCSA 

RHCSA 

MALE 
AGE75 
AGE85 
CHARLSON 

MAJOR 
MINOR 
LARGE 
SMALL 
HRURAL 

LLOS 



lospital 


Inpatient 




Visits 


Consultation 


Echocardioqraphv 


-0.001 


1 .006 ' 


1.003^ 


-0.141 


0.579 " 


1.003 


0.268 ^ 


0.983 


0.953 


-0.186 ' 


1.214 


0.867 


-0.072 


1.375 


1.340 


0.099 


1.139 


1.343 


0.124 


1.680 


0.898 


-0.054 


1.567 


0.584 


-0.078 


4.679 


0.634 


0.066 


1.337 


0.755 


0.065 


0.770 


1.615 


0.008 


0.964 


1.126 


-0.017 


1.008 


0.966 


-0.026 


0.907 


0.841 ^ 


0.001 


0.982 


1.149 


-0.009 


0.905 


0.873 


-0.047 


1.0C4 


1.065 


-0.070 


0.871 


0842 


-0.010 


1.060 


1.010 


0.058 ' 


0.943 


1.036 


0.062 ^ 


0.663 ' 


0.782 ^ 


0.033 ' 


1.085^ 


1 .054 ^ 


-0.130^ 


0.982 


1.215^ 


-0.014 


1 .205 ^ 


0.977 


-0.002 


1.123^ 


1.046 


0.008 


0.469 ^ 


0.552 ' 


-0.080 ^ 


0.603 ^ 


0.787 ' 



Cardiac 


Catheterization 


1.000 


1.090 


1.186' 


1.062 


0.572 


1.478 


0.591 


0.957 


0.550 


1.832 


0.609 


0.646 ^ 


0.716^ 


0.744 ^ 


0.511 ' 


1.165 


0.907 


1.299 


1.183 ^ 


0.349 ^ 


0.057 ^ 


0.697 ' 


1.719^ 


1.319^ 


1 .927 ^ 


0.428 ^ 


0.676 ^ 



1.113 



4-32 



montana\finalrpt\tab4-1 9.xls\ss 



TABLE 4-19 (continued) 

REGRESSION RESULTS: MFS IMPACTS ON AMI PATIENTS 











Revascularization 












(For patients 


Cardiologist 


Independent 




CABG 




undergoing 


as Attending 


Variable 


PICA 


Surqerv 


Revascularization 


cardiac catti) 


Physician 


PRICE91 


1 .000 ^ 


1 .000 " 


1 .000 " 


1.000 


1.008 


MFS 


7.308 ^ 


0.678 


2.271 " 


1.781 


0.508 ' 


Y93 


1 .449 ^ 


0.993 


1.321 " 


1 .240 " 


0.892 


MFS*Y93 


1.967 


0.990 


1.528 


1.610 


0.959 


BLACK*MFS*Y93 


1.060 


0.628 


0.833 


1.269 


0.804 


MEDICAID*MFS*Y93 


1.673 


1.497 


1,930 


1.444 


0.817 


DISABLED*MFS*Y93 


0.404 


0.933 


0.536 


0.579 


2.589 ' 


UPOOR*MFS*Y93 


1.687 


1.287 


1.327 


0.954 


0.794 


RPOOR*MFS*Y93 


0.391 


0.630 


0.396 


0.382 


1.600 


UHCSA*MFS*Y93 


0.879 


1.728 


1.221 


1.461 


0.809 


RHCSA*MFS*Y93 


0.694 


0.654 


0.479 


0.438 


1.650 


BU\CK 


0.697 " 


0.580 ' 


0.573 " 


0.649 " 


0.843 


MEDICAID 


0.744 ' 


0.721 ^ 


0.700 " 


0.814 


0.935 


DISABLED 


0.739 ' 


0.807 ' 


0.683 " 


0.702 " 


0.785 " 


UPOOR 


0.628 ' 


0.734 " 


0.586 " 


0.795 


0.814' 


RPOOR 


0.966 


1.092 


1.019 


0.859 


1.032 


UHCSA 


0.736 


0.994 


0.818 


0.845 


0.913 


RHCSA 


1.113 


1.265 


1.248 


1.067 


1.054 


MALE 


1.134" 


1.157" 


1 .208 " 


1.148" 


1.314" 


AGE75 


0.574 " 


0.498 " 


0.443 " 


0.793 " 


0.668 " 


AGE85 


0.129" 


0.121 " 


0.094 " 


0.821 


0.384 " 


CHARLSON 


0.731 " 


0.836 " 


0.731 " 


0.904 " 


0.917" 


MAJOR 


1.314" 


1.816" 


1.819" 


1.362" 


0.930 


MINOR 


1.126" 


1.479" 


1 .379 " 


1.196" 


1.261 " 


LARGE 


1 .597 " 


1.430" 


1 .750 " 


1 .260 " 


1.269" 


SMALL 


0.369 " 


0.657 " 


0.467 " 


0.892 


0.342 " 


HRURAL 


0.759 " 


0.691 " 


0.696 " 


0.859 


0.500 " 


LLOS 













NOTES: 

' Significant at the 0.05 level. 

" Significant at the 0.10 level. 

SOURCE: 



4-33 



montana\finalrpt\tab4-19.xls\ss 



TABLE 4-20 

REGRESSION RESULTS: MFS IMPACTS ON TiA PATIENTS 









Non-Invasive 


CT Scan 


MRI Scan 


Independent 


Hospital 


Inpatient 


Cerebrovascular 


of the 


of the 


Variable 


Visits 


Consultation 


Tests 


Head 


Brain 


PRICE91 


0.000 


1.011 ' 


1.002' 


1.000 


0.997 


MFS 


-0.020 


0.972 


1.760" 


0.442 


3.441 


Y93 


0.000 


0.852 ' 


1.079 


0.934 


0.820 


MFS*Y93 


-0,120 


1.360 


0.819 


4.315 


0.195 


BLACK*MFS*Y93 


0.017 


1.923 


0.603 


1.152 


0.241 


MEDICAID*MFS*Y93 


0.035 


0.685 


0.696 


1.459 


3.248 


DISABLED*MFS*Y93 


0.009 


0.478 


1.128 


0.293 


0.571 


UPOOR*MFS*Y93 


0.083 


2.281 


0,565 


0.201 


2,992 


RPOOR*MFS*Y93 


-0.CC9 


0.312 


1.114 


0.296 


0,220 


UHCSA*MFS*Y93 


0.189 


0.508 


1.964 


1.130 


0,316 


RHCSA*MFS*Y93 


0.110 


0.120 


0415 


0.263 


0,385 


BLACK 


0.003 


0,854 


0.839 


1.102 


0,758 


MEDICAID 


-0.035 " 


0.844 ' 


0.716" 


1.035 


0,765 


DISABLED 


-0.008 


1.071 


0.907 


0.851 


0,775 


UPOOR 


-0.005 


1 361 ' 


0.952 


1.018 


1.127 


RPOOR 


0.029 


0.964 


1.125 


0.807 


0.897 


UHCSA 


-0 048 


1.005 


1.038 


1.045 


0.695 


RHCSA 


-0.023 


1.026 


0.904 


0,745 


1.015 


MALE 


-0.033 * 


1.114" 


1.172" 


1,196" 


1.478" 


AGE75 


-0.007 


0.814 ' 


0.813" 


0.991 


0.559 " 


AGE85 


-0.037 ' 


0.680 ' 


0.479 " 


0.783 " 


0.231 " 


CHARLSON 


0.012 


1.027 


0.925 ' 


1.037 


0.813" 


MAJOR 


-0.118' 


0.853 


0.712" 


0.798 


1.251 


MINOR 


0.001 


1.227" 


0.970 


0.956 " 


0.946 


LARGE 


0,015 


1.014 


1.057 


0.846 " 


1.350' 


SMALL 


-0.047 ' 


0.328 ' 


0.568 " 


0.720 " 


0.401 '' 


HRURAL 


-0.046 ' 


0.476 " 


0.932 


0.828 " 


0.855 



LLOS 



1.159 



4-34 



montana\finalrpt\tab4-20.xls\nd 



TABLE 4-20 (continued) 

REGRESSION RESULTS: MPS IMPACTS ON TIA PATIENTS 









Carotid 












Endarterectomy 












(For patients 












undergoing 




Neurologist 


Independent 


Cerebral 


Carotid 


cerebral 


Anticoagulant 


as Attending 


Variable 


Anqioqraphv 


Endarterectomv 


anaioaraphv) 


Therapy 


Physician 


PRICE91 


0.987 ^ 


0.999 


1.001 


1.009 


1.021 ' 


MPS 


0.190^ 


1.190 


8.358 


0.146 


0.770 


Y93 


0.728 


0.878 


1.088 


0.567 " 


0.599 ' 


MPS*Y93 


1.535 


1.396 


0.490 


113.729 ' 


1.581 


BLACK*MPS*Y93 


0.784 


0.007 


0.001 


12.577 


2.337 


MEDICAID*MPS*Y93 


0.250 


2.476 


2.695 


0.894 


0.588 


DISABLED*IVIPS*Y93 


1.401 


0.224 


0.189 


0.547 


2.085 


UPOOR*MPS*Y93 


2.972 


1.146 


0.047 


0.665 


0.256 


RPOOR*MPS*Y93 


1.143 


0.219 


0.306 


0.080 


2.162 


UHCSA*MFS*Y93 


0.086 


37.266 


999.000 


0.035 


4.578 


RHCSA*MPS*Y93 


2.141 


2.385 


31.674 


75.398 


1.781 


BLACK 


0.599 ^ 


0.267 " 


0.389 


0.559 


0.761 ' 


MEDICAID 


0.809 


0.839 


0.802 


0.839 


0.822 


DISABLED 


1.040 


0.761 


0.613 


0.913 


1.012 


UPOOR 


0.717 


0.515 


0.534 


0.758 


1.094 


RPOOR 


1.436 


1.173 


1.025 


1.321 


1.017 


UHCSA 


0.739 


0.962 


1.472 


1.277 


0.723 


RHCSA 


1.276 


2.027 


2.895 


0.650 


0.992 


MALE 


1.671 ' 


2.334 ' 


1.653 " 


1.476' 


1.256' 


AGE75 


0.704 ' 


0.708 


1.187 


0.529 ' 


0.832 ' 


AGE85 


0.208 ' 


0.217' 


0.821 


0.278 ' 


0.588 ' 


CHARLSON 


0.870 ' 


1.020 


1.412' 


0.984 


0.973 


MAJOR 


1.074 


2.010" 


2.496 " 


1.086 


1.066 


MINOR 


1.168 


1.781 ' 


1.747 ^ 


1.303 


1.076 


LARGE 


1.559' 


1.242 


1.003 


1.063 


1.520" 


SMALL 


0.549 ' 


0.533 


1238 


0.636 


0.244 " 


HRURAL 


1.038 


1.174 


1.268 


1.063 


0.425 ' 



LLOS 



NOTES: 

' Significant at the 0.05 level. 
" Significant at the 0.10 level. 

SOURCE: 



4-35 



montana\finalfpt\tat)4-20.xls\nd 



TABLE 4-21 

IMPACT OF SPECIALISTS ON UTILIZATION OF TESTS AND PROCEDURES 



NOTE: 

• Significant at 0.05 level or better. 

SOURCE: 



a 



a 



a 



AMI Odds Ratio 

Echocardiography 3.077 

Cardiac Catheterization 4.248 

PICA 2.455 

CABG Surgery 2.725 

Revascularization 1.415 
(for patients undergoing cardiac catheterization) 



TIA 

Non-Invasive Tests 1 -831 

CT Scan, head ''•794 

MRI Scan, brain 3-465 

Cerebral Angiography 1 -860 

Carotid Endarterectomy 1 -202 



a 



a 



a 



a 



Carotid Endarterectomy 0-700 

(for patients undergoing cerebral angiography) 

Anticoagulant Therapy 1 -929 

(for patients with atrial fibrillation) 



4-36 



montana\finalrpt\tab4-21 .xls\ss 



REFERENCES 

Billings, J: Ambulatory Care Access Project . United Hospital Fund of New York, 1991. 

Chamberlain, G: "Analysis of Covanance with Qualitahve Data," Reviezo of Economics and 
Statistics 47:225-238, 1980. 

Charlson, ME, et ai, "A New Method of Classifying Prognostic Comorbidity in Longitudinal 
Studies: Development and Validation", Journal of Chronic Diseases 40:373-383, 1987. 

Deyo, R/., DC Cherkin, and MA Ciul, "Adapting a Clinical Comorbidity Index for Use with 

ICD-9-CM Administrative Databases", Journal of Clinical Epidemiology 45: 613-619, 1992. 

EAFT Study Group, "Secondary Prevention in Non-Rheumatic Atrial Fibrillation After 
Transient Ischemic Attack or Minor Stroke", Lancet 342:1255-62, 1993. 

Hsiao, C: Analysis of Panel Data . N.Y. Cambridge University Press. 1986. 

McGuire TG and MV Pauly, "Physician Response to Fee Changes with Multiple Payors", 
Journal of Health Economics 10: 385-410, 1991. 

Mitchell, JB, DJ Ballard, JP Whisnant et ai, " What Role Do Neurologists Play in Determining 
the Costs and Outcomes of Stroke Patients?", Stroke, November 1996 (a). 

Mitchell, JB, DJ Ballard, JP Whisnant et ai, "Can Differential Access to Neurologists Explain 

Black-White Treatment Differences for Transient Ischemic Attacks?", discussion paper, 
June 1996 (b). 

Mitchell, JB and RK Khandker, "Black-White Treatment Differences in Acute Myocardial 
Infarction", Health Care Financing Revieio 17: 61-70, 1995. 

Mitchell, JB and J Cromwell, "Impact of Medicare Payment Reductions on Access to Surgical 
Services", Health Services Research, 30:637-655, 1995. 

Mitchell JB and J Cromwell, "Physician Behavior under the Medicare Assignment Option", 
Journal df Health Economics 1: 245-264, 1982. 

Oddone, EZ et ai, " Racial Variations in the Rates of Carotid Angiography and Endarterectomy 
in Patients with Stroke and Transient Ischemic Attack", Archives of Internal Medicine 153: 
2781-86, 1993. 

Peterson, ED. et ai, "Racial Variation in Cardiac Procedure Use and Survival Following Acute 
Myocardial Infarction in the Department of Veterans Affairs", JAMA 271: 1175-80, 1994. 

Physician Payment Review Commission. Monitoring Access of Medicare Beneficiaries. No. 95-1. 
Washington D.C.: PPRC, May 1995. 

Udvarheiyi, IS et ai, "Acute Myocardial Infarction in the Medicare Population. Process of Care 
and Clinical Outcomes". JAMA 268: 25:^0-36, 1992. 

R-1 

montana\f malrpt\ ref .doc\ nd 



APPENDICES 



APPENDIX A 



ACCESS VARIABLE DEFINITIONS 



ACCESS VARL\BLE DEFINITIONS 



Variable 



Definition 



NATIONAL SAMPLE 
Office visit 



Emergency room visit 



Hospitalization for ambulatory care sensitive 
condition 



Pap test 

Mammography 
Cataract surgery 



CPT Procedure code-9000a 90010, 90015, 
90017, 90020, 90757, 99201-99205, 99381- 
993S7, 99432, M0005-M0008, 90030, 90040, 
90050, 90060, 90070, 90080, 90750-90755, 
90760-90764, 90774, 95115, 95117, 
99058, 99211-99215, 99391-99397, 99401-99404, 
99411, 99412, 99420, 99429, 99438 

CPT Procedure code-M0059, 90500, 90505, 
90510, 90515, 90517, 90520, 90530, 90540, 
90550, 90560, 90570, 90580, 90590, 99062, 
99064, 99065, 99175, 99281-99285, 99288 

ICD-9-CM principal diagnosis codes: grand 
mal status and other epileptic convulsions 
(345), convulsions (780.3), severe ENT 
infections (382, 462-463,465,472.1), tuberculosis 
(011-018), COPD (491,494,494,496 plus 466 
only if 491,492,494, or 496 is a secondary 
diagnosis), bacterial pneumonia 
(481,482.2,482.4,482.9,483-486), asthma (493), 
congestive heart failure 
(428,402.01,402.11,402.91,518.4), hypertension 
(401.0,401.9,402.00,402.10,402.90), angina 
without accompanying surgery 
(411.1,411.8,413), celluUtis (681-683,686), 
diabetes (250.x), hypoglycemia, unspecified 
(251.2), gastroenteritis (558.9), kidney/ urinary 
infection (590, 599.0,599.9), dehydration 
(276.5), nutritional deficiencies (260- 
262,268.0,268.1), pelvic inflammatory disease 
(614), dental condihons (521-523,525,528). 

CPT Procedure code=88150-88157, Q0060, 
Q0061, Q0063, Q0091, P3000, P3001 

CPT Procedure code=76090-76092 

CPT Procedure code=66830, 66840, 66850, 
66852, 66915, 66920, 66930, 66940, 66945, 
66983-66986 



montana\finalrpt\apndx-a.doc\nd 



A-1 



EPISODE OF CARE ANALYSIS 
Hospital visits 



Consults 



AMI Only 
Echocardiograms 



Cardiac catheterization 



FTCA 



CPT Procedure code= 90200-90292, 99217- 
99238, M0021-M0022 

CPT Procedure code=90600-90654, 99251- 

99275 



CPT procedure code=93300-93350 or ICD-9 
procedure code=88.72 

CPT procedure code= 75750-75775, 93510- 
93529, 93539-93556 or ICD-9 procedure 
code-37.22, 37.23, 88.53-88.57 

CPT procedure code=92982, 92984 or ICD-9 
procedure code=36.0x 



CABG 



TIA Only 

Noninvasive cerebrovascular tests 



Head CT scan 
Brain MRI scan 
Cerebral angiography 
Carotid endarterectomy 
Prothrombin time tests 



CPT procedure code=33510-33636 or ICD-9 
procedure code=36.1x, 36.2 and type of 
service=surgery 



CPT procedure code=93850-93888 or ICD-9 
procedure code=88.71 

CPT procedure code=70450-70470 or ICD-9 
procedure code=87.03 

CPT procedure code=70551-70553 or ICD-9 
procedure code=88.91 

CPT procedure code=75660-75682 or ICD-9 
procedure code=88.41 

CPT procedure code=35301 or ICD-9 
procedure code= 38.12 

CPT procedure code=85610 



montana\ finalrpl\ apndx-a.doc\nd 



A-2 



APPENDIX B 



PRICE VARIABLE DEFINITIONS 



PRICE VARIABLE DEFINITIONS 



Variable 



Definition 



NATIONAL SAMPLE 
Office visit 



CPT Procedure code=90000, 90010, 90015, 
90017, 90020, 90757, 99201-99205, 99381- 
99387, 99432, M0005-M0008, 90030, ^0040, 
90050, 90060, 90070, 90080, 90750-90755, 
90760-90764, 90774, 95115, 95117, 
99058, 99211-99215, 99391-99397, 99401-99404, 
99411, 99412, 99420, 99429, 99438 



Mammography 
Cataract surgery 



CPT Procedure code=76090-76092 

CPT Procedure code=66984 and 

primary modifier code=missing, LT, QB, QU, 

orRT 



EPISODE OF CARE ANLAYSIS 
Hospital visits 



CPT Procedure code=90200-90292, 99217- 
99238, M0021-M0022 



Consults 



CPT Procedure code=90600-90654, 99251- 
99275 



AMI Only 
Echocardiograms 



CPT Procedure code=93307-93312, 93320- 
93350 



Cardiac catheterization 



CPT Procedure code=93547 



PTCA 



CABG 



CPT Procedure code=92982 

1991 and 1992: CPT Procedure code=33510- 
33516 and type of service=surgery 
1993: CPT Procedure code=33510-33516, 
33533-33545 and type of service=surgery 



TIA Only 

Noninvasive cerebrovascular tests 



1991: CPT Procedure code=93870 

1992 and 1993: CPT Procedure code=93880 



Head CT scan 



CPT Procedure code=70450-70470 and 
primary modifier code=26 



montana\finalrpt\apndx-b.doc\nd 



B-1 



Brain MRI 



Cerebral angiography 



Carotid endartarectomy 



CPT Procedure code=70551 -70552 and 
primary modifier code=26 

CPT Procedure code=75650, 75652, 75654, 
75656, 75658, 75660, 75662, 75665, 75671, 
75676, 75680, 75685 

CPT Procedure code=35301 and type of 
service=surgery 



montana\ f inalq>t\apndx-b.doc\ nd 



B-2 



APPENDIX C 

DETAILED DESCRIPTIVE TABLES FOR 
NATIONAL SAMPLE 



TABLE C-1 

OUTPATIENT VISITS BY EXPECTED MFS PAYMENT CHANGE AREAS AND VULNERABLE POPULATION GROUPS, 1991-1993 (age - sex adjusted visits per beneficiary) 

















EXPECTED MFS PAYMENT CHANGE AREAS 














ALL AREA 








Raductloi 
1 


^ 


























^ 


Increase 
6 






Vulnerable 
PoDulation 


n •^^ 




2 






3 






4 






S 




P- 


lS 


1991 


199? 


1993 


1991 


199? 


1993 


1991 


1992 


1993 


1991 


199? 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


Shortaae Areas 












































All Shortage Combined 

Urban 

Rural 
Non -Shortage 


6.07' 
6 11 • 
2 94' 
6.78 


5 96 • 

6 00' 
315* 
6 69 


5 90" 

5 95 " 
2 93 • 

6 70 " 


4 81 ■ 

4 72 • 

5 06 • 
5 42 


4 82* 
4 71 • 

5.13 • 
551 


4 82 ■ 

4 68 ■ 

5 24 •» 
5 63 » 


4 62- 
4 61 ' 

4 64 ■ 

5 15 


4 56» 
4 59 • 
4 42 • 
5.17 


4.48 «> 

4 54 ' 
4.16 " 

5 22 


4 85 • 

5 16 • 

4 33 • 

5 04 


4.96 • 
5 31 

4 36 • 

5 21 


4 98» 

5 36 ' 

4 34 • 

5 29 " 


4 52- 
4.92 • 
4.33 • 
4 84 


4 63- 

4 98 

4 48 • 

5 01 


4 62* 

5 02° 
4 44 * 
5.06 ° 


4 56* 
4 29" 

4 71 ■ 
4 77 


4.65" 
4.34 • 
483 
4 84 


4 59« 
4.32 • 
4 73 • 
4 86 » 


4 72- 
4 91 ' 

4 43 ' 

5 12 


4 78 - 
4 96 ' 

4 49 " 

5 23 


4 76 «, 
4 96 «. 

4 44 , 

5 29 1 


Poor Areas 












































All Poor Combined 

Urban 

Rural 
Non Poor 


8 23" 
8 32' 
2.74' 
6.67 


7 82- 
7 92 ■ 
2 78 • 
661 


881 " 
8 92 » 
3 02"' 
6 57 ' 


4 71 • 

4 68 • 

5 03 • 
5 43 


4 75 • 

4 70 • 
531 • 

5 52 


4 72 • 

4 68 • 
512 ■ 

5 65 » 


4 79 • 
4 77 ' 

4 86 • 

5 16 


4.80" 
481 • 
4 68- 
518 


4 80 • 
4 85 • 
4 49 « 
522 


518" 
5 29" 

4 54 • 

5 01 


5.28 
5 40 • 

4 59 • 

5 18 


531 » 
5 42* 

4 69 * 

5 27 " 


4 94 ' 

4 89 • 

5 02 • 
481 


5 04 
4 96 
516 • 
4 99 


5 07° 

4 97 » 

5 21 " 
5 02° 


4 94- 

4 42 • 
512 • 
4 75 


4 92 ■ 

4 42* 

5 09 • 
4 82 


4 90 »- 

4 47 ^ 

5 04 * 
4 85 <■■ 


5 07 • 
5 12 

4 89 • 

5 10 


5.11 " 
5 17 ' 

4 89 " 

5 21 


5 15 * 
5 23 .1, 

4 86 . 

5 ?7 . 


Races 












































Black 
White 


5.61 • 
6 87 


5.37 ■ 
6.78 


5 41 * 

6.79 » 


4 42 • 

5 35 


4.50" 
563 


4 56 " 

5 75 » 


4 56 • 
526 


-159 • 
5 25 


4 57 ■ 

5 29 


4 68 • 

e 13 


4 87 • 

5 28 


4 86 * 
5.37 » 


4.89 
4 90 


496 " 
5 05 


4 92- 

5 09° 


4 62 • 

4 86 


4 59" 
4 91 


4 58 • 
4 92° 


4 67 » 
^21 


4 75 • 

5 30 


A 74 u, 
5 36 t. 


Medicaid Ellalble 












































Yes 
No 


8.15 • 
6 55 


8 01 • 
6.47 


8 40 * 
6 42 » 


5 98 ' 
5 33 


5 92' 
544 


5 88 «■ 
5-57 » 


5 95' 
5.02 


5 79" 
5.06 


5 60 » 
5 12 » 


5 29- 
5 00 


5 36' 
5 18 


519 
5.29- 


5.17' 
4.78 


5 20 • 
497 


5 02 ° 
5.03 ° 


5 63» 
463 


5 59- 
4 71 


5 33 •° 
4 77 ° 


5 71 • 
503 


5 67 " 
5 15 


5 53 * 
5 24 I. 


Disabled 












































Yes 
No 


7.56' 
669 


7 48 • 
660 


7 39» 
662 


5 86 ' 
5.35 


5.92' 
5.44 


5 96" 
5 56° 


5.44 • 
509 


5 46 ■ 
510 


5 42 ' 
515 


5.31 ■ 
4 99 


5 45 " 
516 


5.44* 
5.26° 


5.21 ' 
477 


5.36 • 
495 


5 32° 
4 99° 


5 12 ' 
4.72 


519- 
4.78 


5,14 • 
4.81 ° 


5 43 ' 
5.06 


5 52 ' 
517 


5 50 .. 
5 24 ,. 


Age 












































85-1- Years 
Less than 85 


6 43 • 

6.77 


6 31 • 
668 


6 39 • 
669 


4.71 • 
541 


4 78« 
5.50 


4 83 » 
5.63 » 


4.16 • 
5.15 


4 17 ' 
5.17 


415 = 
5 21 


419 ■ 
5.05 


4 37 ■ 
522 


4 34 * 
5.31 - 


3.93 ' 
4.84 


4.08 • 
502 


4 06 » 

5 06 ° 


3 97 ■ 
4.79 


4 04 • 
4 85 


4.00 '^ 
4.88 ° 


4 26 • 

512 


4 36 « 

5 23 


A3b .L 

5 30 I 


Area of Residence 












































Rural 
Urban 


4 98 ■ 
682 


4.91 • 
6 73 


5 01 • 

6 74" 


535 
540 


5.49 
548 


5.73 «> 
5.58" 


4.80 • 
5.19 


4.70 • 
5.23 


4 63 * 

5 29 


4 51 • 
514 


4 73 • 

5 32 


4 72 * 

5 43 » 


4 62 • 
4 99 


4 79 • 

5 17 


4.82 ■«■ 
5 21 ° 


4 79 ■ 
472 


4 85 • 
478 


4 86 " 
4 83 ° 


4 72 ' 

5 25 


4 81 • 

5 36 


4 62 ^ 

5 44 .- 


ALL BENEFICIARIES 


6.76 


6.67 


6 68» 


539 


5.48 


5.60 » 


5.12 


514 


5.17 


5 03 


519 


5 28 " 


4 82 


4 99 


5.03 - 


477 


483 


4.85 ° 


5 10 


5 20 


6 27 , 



NOTES 

■ Slgnlflcwtly dJ«er.nl from Ihe comptiUon group at me 05 level. 
" SlgnidMrtly ditferenl from 1991 lo 1993 at the 0.05 level 



SOURCE CHER anafysis 



of Medicare Part B claims and denomlnato. file tor a sample of beneficiartes. 



monttina\flnalfpl\diJ[iru i:\ldtilt.", m-,V 1j 



TABLE C-2 

EMERGENCY ROOM VISITS BY EXPECTED MFS PAYMENT CHANGE AREAS AND VULNERABLE POPULATION GROUPS, 1991-1993 (age - sex adjusted visits per beneficiary) 



Vulnerable 
Population 



EXPECTED MFS PAYMENT CHANGE AREAS 



Reduction ■^ 
1 



991 1992 1993 1991 1992 



1993 



1991 1992 1993 1991 1992 1993 



1991 1992 



1993 



Increase 
6 



1991 



1992 1993 



ALL AREAS 



1991 1992 



1933 



Shoitaoe Areas 

All Shortage Combined 0.31 ' 

Urban 0.31 ' 

Rural 0.14 ' 

Non-Stiortage 0.26 



0.31 • 


0.30' 


0.38' 


0.40' 


0.39 


0.32 • 


0.30' 


0.40' 


0.42 ■ 


0.41 


0.14' 


0.10" 


0.33* 


0.36' 


035 


0.25 


0.25" 


0.29 


0.29 


0.30 



40 • 0.35 • 0.37 ' 

0.42 • 0.37 • 0.39 ' 

0.24 • 0.23 • 0.25 ' 

0.32 0.30 0.33 



0.39 " 0.35 • 0.38 « 0.36 • 31 0.32 " 0.37 ■ 

44 ' 38 • 0.40 " 0.39 " 0.39 ■ 0.41 «> 35 ' 

30 29 33 ' 0.35 " 0.27 • 0.29 " 38 ■ 

31 0.29 0.32 33 0.32 0.33 33 



35 " 0.36 ' 

0.36 • 36 ' 

0.34 • 0.36 ' 

33 0.35 ' 



0.38 " 34 - 36 

0.42 ' 0.33 " 0.40 ■ 

0.32 » 0,28 ' 31 

0.31 0.30 32 • 





Poor Areas 














































All Poor Combined 

Urban 

Rural 
Non Poor 


0.37' 
0.38' 
0.28' 
0.25 


0.35- 
0.36' 
0.19' 
0.24 


0.34- 
0.34 » 
0.41 - 
0.24 


0.39' 
0.40' 
0.31 • 
0.29 


0.40' 
0.41 • 
0.34' 
0.29 


42 •" 
0.42 " 
0.35 » 
0.30" 


0.44' 
0.45' 
0.34' 
032 


0.38' 
0.39' 
0.32 • 
0.30 


0.41 •" 
0.42 •" 
0.35 •« 
0.32 


0.39' 
0.38' 
0.40' 
031 


0.34 ' 
0.34 ' 
0.38" 
0.29 


0.37 •" 
0.36' 
0.42 " 
0.32 


0.43 • 
0.47 ' 
0.37' 
0.33 


0.43' 
0.48' 
0.37' 
0.31 


0.46 •" 
0.49 "» 
0.42 •" 
0.33 


0.37' 
0.37' 
0.37' 
0.33 


0.38' 
0.38' 
38' 
32 


0.41 « 
0.38' 
0.42 « 
0.35 ' 


0.41 • 
0.42 ' 
0.37' 
0.31 


0,37 • 
0.37 ' 
0,35" 
030 


040 
040 
040 
0,32 




Races 












































T 


Black 
White 


0.44' 
0.26 


0.42' 
0.25 


0.40* 
0.25- 


0.4h ■ 
0.28 


0.46 • 
0.28 


0.49 •» 
0.30 


0.48 ■ 
0.32 


0.45" 
0.30 


48- 
0.32 


0.48' 
0.31 


44 • 
0.29 


0.47' 
0.31 


0.48' 
0.33 


0,48 ' 
0.31 


0.51 " 
0.32 


0.45' 
0.32 


0.46' 
0.32 


50 " 
0,34 ' 


47 ' 
0,31 


0,45 ' 
0.29 


48 
31 


to 


Medicaid Ellaible 














































Yes 
No 


0.55 • 
0.22 


0.53' 
0.21 


0.54' 
0.21 ' 


0.71 • 
0.25 


0.73' 
0.25 


0.73'" 
0.26" 


0,69 • 
0.28 


0.66' 
0.26 


0.70' 
0.28 


0.70' 
0.28 


67 ' 
0.26 


0.71 • 
028 


0.72' 
0.30 


0.71 ' 
0.28 


0.75 " 
29' 


0.70' 
0.27 


0.71 ■ 
0.27 


0,74 " 
0.28" 


69" 
0,28 


0,68 ' 
026 


71 
0,28 




Disabled 














































Yes 
No 


0.49' 
0.24 


0.48" 
0.23 


0.47"' 
0.23 ■■ 


0.55 • 
0.27 


0.56' 
0.27 


0.58"" 
0.28" 


0.58' 
0.30 


0.55- 
0.28 


0.60' 
0.30 


0.56' 
0.29 


0.54' 
0.27 


0.57' 
0.29 


0.59' 
0.30 


0.57' 
029 


0.60' 
030 


0.57" 
0,30 


0.59" 
029 


0.52 " 
0,31 ' 


0,57 • 
0,29 


0,56 " 
0,28 


59 
29 




£Bfi 














































85+ Years 
Less than 85 


0.49" 
0.25 


0.49" 
0.24 


0.49- 
0.24- 


0.54' 
0.29 


0.55" 
0.29 


OSS* 
0.30" 


0.56 • 
0.32 


0.53 • 
0.30 


0.56- 
0.32 


0.50' 
0.31 


0.51 ° 
029 


0.53 •" 
031 


0.53' 
0.33 


0.52 • 
0.31 


0.53' 
0.33 


0.55' 
033 


0.56' 
0,32 


0,59 »" 
0,34" 


0,53' 
0.31 


53 ■ 
30 


0,54 
0.32 




Area of Residence 














































Rural 
Urban 


0.24' 
0.26 


0.24 
0.25 


0.26* 
0.25 » 


0.30' 
0.29 


0.31 • 
0.29 


0.32 •" 
0.30" 


0.31 • 
0.33 


0.30 
0.31 


0.33" 
0.33 


0.30 
0.32 


0,29 
0.30 


0.32" 
0.32 


0.34 
0.33 


31 ' 
0.33 


0.32 ' 
034 


0.34' 
0.31 


34' 
0.30 


0.37 '" 
0.31 


0,32 
0,32 


031 " 
0,30 


0,33 
32 




ALL BENEFICIARIES 


0.26 


0.25 


0.25" 


0.29 


0.29 


0.31 " 


0.33 


0.31 


0.33 


0.31 


0.30 


0.32 


0.33 


0.32 


0.33 


0.33 


0.33 


0,35 " 


0,32 


0,30 


032 

















































NOTES: 

■ SIgntllcantty dinereni (rom Ihe comparison groip at Itie 0,05 level 
> Significantly anerent from 1991 to 1993 at Itie 0,05 level 

SOURCE: CHER analysis of Medicare Part B claims and denominator file for a sample of beneficiartes. 



nionldna\/inalrpt\dppni]> c\l dt4. 



TABLE C-3 

AMBULATORY CARE SENSITIVE (ACS) HOSPITAL ADMISSION RATES BY EXPECTED MPS PAYMENT CHANGE AREAS AND VULNERABLE POPULMION GROUPS, 1991-1993 (age ■ sex adjusted admissions per 1 ,000 t^eneficiaries) 



Vulnerable 
Population 



Reduction 



1991 



1992 



1993 



EXPECTED MFS PAYMENT CHANGE AREAS 



1991 1992 1993 1991 1992 1993 1991 1992 1993 1991 



1992 



1993 



~W' Increase 
6 



1991 



1992 



ALL AREAS 



1991 



1992 



1993 



Shortage Areas 








All Shortage Combined 

Urban 

Rural 
Non-Shortage 


64 9 ' 

65 0" 
588 
49,0 


68 0" 
68 2" 
586 
475 


617" 
618" 
528 
474 


Poor Areas 








All Poor Combined 

Urban 

Rural 
Non Poor 


803" 
807* 
58 3* 
476 


82 " 
82 4" 
59 4 
460 


79 6" 
803" 
40 4° 
461 


Races 








~1 Black 
jo White 


80.2" 
49 6 


84 6 " 
477 


79 0" 
47.7 


Medicaid Eligible 








Yes 
No 


109 1 ' 
40,5 


105-8 ■ 
39,4 


106£" 
390 


Disabled 








Yes 

No 


957" 
452 


96 9* 
436 


94 5" 
43 6 



72,5* 71,0" 75 4"^ 

79 ■ 78 5 " 84 1 " 

524 48 8 " 49 9 " 

53 6 53 8 56 



76 2 ' 79 8 " 83 7 " 

75 " 78.0 " 82 6 * 

90.9 " 101 " 97 1 ' 

53 2 531 554 



865" 


85 9 " 


90 ' 


68 1 * 


70 4 ■ 


73 1 ■' 


624 


653 


71 7 "^ 


74 1 ' 


72 3 " 


78 1 " 


718' 


73 1 ' 


77 1 


89 7 " 


900 " 


94 3 ■ 


70 5 ' 


75 ° 


783" 


70 1 • 


720" 


78 8"' 


719' 


70 8 


719 


77 7° 


79 7 ° 


83 6 


66 5 


61 5 


64.9 


639 


62 6 


64 3 


58 8 


62 2 


684' 


752* 


73 2" 


81.3 •' 


62 5 


62 6 


669 


64 4 


64 8 


65 3 


59 9 


59 7 


63 9 


61 4 


62 7 


65 6' 


682 


68 2 


70 6 


60 8 


610 


63 5 



84 7 " 84 5 ' 88 1 ' 

84 8' 84 9' 88 5* 

84 1 " 81 7 ' 86 ■ 

63 5 63 9 64 3 



72 7" 


74 8" 


82.3"" 


82.5 " 


819 " 


88 3"° 


846" 


85 8* 


883 


70 4 " 


72 3* 


784 -^ 


75 5 " 


77.5" 


85.4" 


693 


655 


58 6 


86 2 ' 


89 7* 


104.5*" 


931 " 


88 3" 


92 4" 


89,7 " 


92 4 * 


94 7 


59 2 


59 1 


62 8 


606 


62 1 


65,1 ' 


67,1 


669 


69 5 



79 1 * 80 2 * 85 3 ' 

76 6 " 77,8 " 82 6 ' 

88 2 ' 88 8 " 94 9 ■ 

59 9 60 2 62 6 ' 



82 4 " 


810" 


863" 


91 9' 


93 * 


96 8 " 


811 • 


84 3* 


86 f " 


82 5* 


84 5 ' 


89 2 " 


806 * 


819* 


883 ' 


84 2 ' 


85 1 ' 


89 8 


52 9 


526 


54 9 


63 6 


640 


64 


589 


58 7 


62 8 


599 


61 1 


64 6 ' 


672 


67.1 


692 


59 8 


59 9 


62 4 



127 7 " 1257 • 1320 ' 
46 4 46 5 48 1 



105.3 * 104.0 " 108.3 " 
489 491 512 



142 9* 


143 4 " 


143 6 * 


133 " 


134.6' 


141,6 * 


140 9 ' 


142 1 * 


1517*' 


142 5 * 


144,1 • 


1452 * 


136 1 * 


136 7 ° 


141 3 ' 


56 2 


561 


564 


53 7 


53 4 


568 


53 9 


55,1 


57 1 


56 9 


56.1 


58,1 


53 2 


53 3 


55 2' 



1171° 1184* 1160" 1063* 1099° 1136" lll.o' 
59 8 59 9 60 9 55 2 54 8 58 9 55 7 



115 2' 1209°' 1202" 1207* 1250' 
56 7 59 5 ' 61 3 610 63 2 



1107 1129' 1155' 
55 8 55 7 58 3 ' 



Age 



85+ Years 
Less than 85 


112.8" 
47.7 


118.1 • 
46.0 


1125* 
457 


120 6 " 
52.6 


1188 ' 
52,7 


123 1 " 
547 


1448 
63 5 


140 9 
638 


142.0 
64 2 


126.2 
585 


132 4 
583 


133 1 * 
62 1 


123 5 ° 
59 8 


124 9 ' 
61.1 


124,3 " 
64 1 ' 


142 3 ' 
66 5 


1396 " 
66 4 


1460 * 
685 


130 3 ' 
59 5 


131 6 ° 
59 6 


132 8"' 
62 0' 


Area of Residence 












































Rural 
Urban 


47.4 
49,5 


493 
47.9 


51.1"' 
47.7 


524 
54,6 


535 
54,5 


53.2* 
57.2 


74 3" 
64 


71 6 ■ 
64.8 


75.5" 
649 


668* 
585 


685" 
58.1 


70.0" 
62 8 


64.7 " 
58 6 


65 8* 
602 


69 3 * 
63 1 ' 


74 3* 
54 2 


74 4 ' 
53 5 


771 ° 
55 9 


68 ° 
588 


68 5 ■■ 
59 


71 1 ■" 
61 5 ■ 


ALL BENEFICIARIES 


49,4 


480 


47,8 


54,3 


54.4 


56.7 


65 7 


66.1 


66 7 


60.3 


604 


64 4 


61 5 


63.0 


66 0' 


684 


68 3 


70 8 


61 4 


61 6 


64 2 ' 



NOTES: 

' SionHlcinlly dlltorenl from Iha comparison group at th« 05 lovd 
' Signiflcanlly dilteranl from 1991 lo 19S3 at tlw 0,05 lavol, 

SOURCE CHER analysis o( Medicare Part A claim, and denominalof file (or a sample oT Penelidanes 



rn-.iiildnj\ftfwli|jr>jp[,ii.<-(,iI.il'l<T-. n 



TABLE C-4 

MAMMOGRAPHY RATE BY EXPECTED MPS PAYMENT CHANGE AREAS AND VULNERABLE POPULATION GROUPS, 1991-1993 (age - adjusted percent of female beneficiaries) 





Vulnerabl* 






















EXPECTED MFS PAYMENT CHANGE AREAS 






























Reduction 


1 


^ 




































^ 


Increase 












































w 






PoDulatlon 




1 










2 
















4 








5 










6 






ALL AREA"? 




1991 


1992 




199; 


1 


1991 


1992 


1993 




1991 


1992 


1993 




1991 


1992 


1993 




1991 


1992 




1993 




1991 


1992 


1993 


1991 


1992 


1993 




Shoftaae Areas 




























































All Stiortage Combined 

Urban 

Rural 
Non-Shortage 


243% 
24 4 
192 
33.2 


• 223% 

• 223 

• 17.9 
313 


a 
• 
• 


22 6% 
22.8 
108 
29.5 


ab 
aD 


19.8% • 
176 • 
273 • 
297 


21 0% < 
192 • 
268 • 
298 


20 5% 
187 
26.6 
293 


at 
ab 
ab 


18 7% 
184 
20 3 
25.0 


a 19 1% • 

• 189 • 

• 205 • 
251 


192% 
19.1 
198 
246 


ab 


22 8% a 
22.2 • 
237 a 
256 


23 7% • 
23 4 • 
24.4 a 
264 


23 2% 
22 7 

24 1 

25 3 


• 


24.0% a 
23.4 a 

244 > 
26.3 


24.6% 
239 
249 
26.9 


< 


23 7% 
238 
23.6 
259 


• 


21 4% a 

215 > 
214 a 
226 


22.0% ' 
21.8 a 

220 a 

22.9 


20 9% » 
21.0 - 
20 9 ' 
222 


218% 
207 
236 
261 


' 2^ 5% » 

' 215 ' 

a 24 1 ' 

265 


22 0% • 
21 2 •' 

23 3 - 
25 6 >' 




Poor Areas 




























































All Poor Combined 

Urban 

Rural 
Non Poor 


212 
21.2 
16.3 
337 


. 193 

• 193 

• 165 
318 


• 


188 
188 
14.0 
299 


a 


170 • 
166 • 
219 • 
300 


1/9 ■ 
17.4 • 
244 • 

301 


178 
17 3 
245 
296 


ab 
ab 


189 
197 
131, 
25 3 


a 199 a 

• 207 a 

• 152 " 
25.3 


194 
20 1 
152 
24 9 


!b 


199 a 

20.1 • 
189 • 
25 9 


20 9 ' 
20 9 • 
20 8 ■ 
26 7 


20 2 
204 
193 
25 7 


• 


21.7 , 
237 a 
185 a 
26 4 


22 4 

23 6 
206 
269 


« 


21.7 
225 
20,4 
26 


ab 

ab 


170 ■ 
168 • 

171 a 
23 


179 . 
172 a 
181 • 
23.3 


17 9 « 
169 • 

18 3 ■" 
22 5 


194 
19 9 
173 
26 4 


• 20 2 « 

- 20 6 • 

' 188 ' 

26 7 


197 ■« 
20 ■■ 
185 ' 
25 9 - 




RacM 




























































Black 
WIMta 


182 
34 5 


■ 167 
32 7 


• 


166 

31.0 


ae 


159 • 
31 


17,5 • 
309 


17.4 
30 4 


ab 


16 4 
26 


a 17.6 a 

260 


179 
25 4 


ao 


183 " 
26 6 


20 1 ' 
27 1 


193 
261 


ab 


189 a 

27 4 


20.1 
27 7 


• 


201 
265 


ab 

b 


131 a 
24 1 


14 1 a 

24 2 


14 1 * 
234 > 


171 
27 2 


■' 18 5 • 
27 4 


18 3 ■' 
26 5 - 


o 
1 


Medicaid Ellolble 


























































4^ 


Yes 
No 

Disabled 


159 
35.9 


• 155 
33 7 




15.1 
31.8 


ab 
D 


15.1 ■ 
31 1 


159 • 
313 


154 
50 8 




134 
26 2 


a 144 • 

26 3 


139 
26 C 




146 " 
26 6 


15 6 » 
27 4 


152 
26 4 




137 • 

:/6 


151 
28 1 




14.0 
27 3 




109 a 
24 7 


12.2 - 
249 


119 * 
24 3 


138 
27.4 


•148 ' 
27 8 


14 3 ■ 
27 (■. ' 




Yas 
No 


265 

334 


• 258 

31.4 


a 


246 
296 


tf> 


23.0 • 
297 


235 • 
299 


22 4 
29.5 


ab 


193 
25 


" 20.0 • 
252 


199 
247 


■ 


20 9 • 
25 8 


219 ' 
26 5 


21 1 
25 5 


■ 


20 9 • 
26 6 


21 7 
27 1 


• 


214 
26 1 


• 


176 • 
230 


177 • 
23 3 


176 • 
22 6 


206 
26 3 


' 213 " 
26 6 


20 8 • 

25 8 ■ 




Am 




























































85+ Years 
Less than 85 


86 

33.9 


■ 87 

31.9 


a 


8.4 
30.3 


a 
b 


67 • 
301 


76 • 
303 


72 
299 


. 


53 
25 4 


" 58 ■ 
25 6 


5.9 
25 2 




57 • 
262 


61 • 
27 


5.9 
261 


^ 


56 « 
270 


62 
27 6 


* 


61 
26.7 


" 


47 • 
23 2 


5.1 a 
236 


5 1 «• 
22 9 


57 
26 6 


' 6 2 ■' 
27 1 


6 1 ' 

26 3 




Area of Residence 




























































Rural 
Urban 


257 

332 


• 24 4 

31 3 


a 


235 
295 


ab 


317 • 
290 


31 7 • 
29.2 


31.5 
286 


' 


188 
258 


■ 197 • 
25.8 


198 
25 2 


ab 


247 • 
25.6 


252 • 
265 


239 
25 6 


' 


24 3 a 
27 9 


25 1 
28.2 


• 


239 
27.5 


• 


21 1 a 
26.0 


21.6 a 
26 


210 ■ 
24 9 t. 


23 3 
26 8 


•23 9 .. 
27 1 


23 1 ■ 
25 3 ■' 




ALL BENEFICIARIES 


33.0 


31 1 




294 


_ 


29.3 


295 


29.0 


M^ 


24.6 


24.8 


243 


__ 


25.4 


26 2 


252 




26 2 


26.8 


_ 


25 8 




225 


22 9 


22 2 


25 9 


26.3 


25 4 ' 



NOTES: 

• Slgniflcamly differtnl (rom lh« compinton group at lh« 0.05 lev«), 
' SlgnKlcamly dlflM.nt »om 1981 lo 1983 il th« 0,05 lev.1 

SOURCE: CHER analysis o( rjedloare Part B claims and d^mmlnalor «1« for a lampla of b.n«llclan«s. 



niontana\nt)aliFrlUpp(i> 



TABLE C-5 

PAP TEST RATE BY EXPECTED MPS PAYMENT CHANGE AREAS AND VULNERABLE POPULATION GROUPS, 1991-1993 (age - adjusted percent of female beneficianes) 



Vulnerable 
Population 



EXPECTED MFS PAYMENT CHANGE AREAS 



Reduction 
1 



1991 1922 li23 



1991 



1992 



1993 



1991 



1992 



1993 



1992 



1991 



1992 



1993 



1991 



Increase 
6 



1992 



1993 



ALL AREAS 



1991 1992 1?93 



Shortage Areas 

All Shortage Combined 

Urban 

Rural 
Non-Shortage 



13 4% " 134% • 12 7% ' 

13.5 * 13 5 • 12,8 ' 

86 • 86 ' 79 ' 

19 19.1 17 8 ' 



9 7% ■ 


10 7% ■ 


10 4% " 


9 4% • 


9 4% ' 


9 5% • 


116% " 


117%' 


11.7% • 


13 0% • 


12 8% " 


12.3% » 


12.6% ■ 


12 7% • 


111%" 


1 1 3% " 


1 1 4% ■■ 


1 1 2% 


90 ■ 


9.4 • 


94 " 


91 ■ 


92. " 


96 • 


109 * 


11 2 • 


11.1 • 


11 • 


110 * 


107 • 


134 • 


134 • 


118 "- 


10 3 ' 


105 ^ 


10 5 


122 • 


14.9 ' 


138 " 


109 • 


106 • 


9 ■" 


128 • 


126 ' 


127 ■ 


140 


137 ■ 


130 » 


12.1 


123 


10 7 *■ 


13 1 ' 


12 9 " 


123 


172 


172 


16.4 » 


13 6 


13.4 


12.7 ' 


137 


140 


136 


14.4 


142 


13.3 ' 


119 


120 


112 '■ 


143 


143 


136 



Poor Areas 

All Poor Combined 

Urban 

Rural 
Non Poor 



11.3 


• 10.8 


' 104 


11.3 


• 109 


■ 104 


8,3 


■ 38 


■ 58 


194 


195 


18 1 



0.5 


• 10.1 


■ 107 


05 


• 10.0 


• 105 


02 


• 115 


■ 130 


73 


173 


165 



10 1 


103 


98 • 


99 


■ 101 


98 


10 3 


106 


103 ' 


100 


101 


99 


87 


• 82 


■ 7 " 


95 


■ 99 


95 


138 


13.5 


12,9 " 


140 


142 


138 



117 ■ 116 • 10,9 

118 • 11,7 " 10,2 
117 " 11,5 • 119 
145 143 133 



97 


■ 104 


' 97 


* 


102 


' 104 


' 100 


103 


• 102 


• 103 


"" 


103 


' 104 


• 101 


95 


' 105 


• 95 


- 


98 


" 101 


' 9 5 


121 


122 


113 


' 


144 


145 


13B 



o 
I 

Ul 



Races 



Black 
V/hite 



Medicaid Eligible 

Yes 
No 



94 

19 4 



97 
196 



88 
18,1 



95 

178 



98 

177 



100 
16,9 



9,4 


• 88 


• 88 «■ 


8,5 


■ 90 


88 


206 


207 


19.2 " 


180 


179 


17,2 



94 
14 1 



79 
14,2 



94 
138 



81 
140 



96 

131 



77 
133 



91 
14 3 



78 
142 



93 

145 



81 
145 



92 
140 



80 
14,1 



10 2 

150 



150 



104 
147 



99 
137 



83 
126 



86 
126 



80 
11 7 



93 
148 



95 

148 



94 

140 



86 


• 78 ■« 


70 


75 


• 68 " 


81 


83 


79 


" 


148 


13 9 '' 


128 


129 


121 ' 


149 


149 


143 


t. 



Disabled 



Yes 

No 



152 


• 15.1 


• 141 


m 


12.6 


• 13 


' 124 ■ 


10,3 


■ 105 


' 104 • 


112 


• 11 4 


■ 112 • 


119 


■ 11 4 


' 11,0 " 


96 


■ 98 


S 1 


* 


11 2 






191 


192 


17.9 


t 


172 


17.2 


165 ' 


136 


13,4 


127 ■> 


13,8 


140 


13,7 


14,5 


144 


13,4 ' 


12 1 


122 


11,4 


t 


143 


144 


13 7 



Aas 



85+ Years 
i.ess than 85 


5,6 
19,4 


58 
195 


■ 51 
182 




4,9 
174 


49 
174 


5,0 ' 
167 =■ 


35 
138 


■ 36 
136 


36 
13,0 


ao 


38 
14,0 


39 
143 


3 3 « 
139 


41 
14,7 


38 

146 


' 34 
137 


: 


34 
122 


36 
124 


3 "'■ 
116 '- 


40 
145 


' 40 
146 


3 6 " 


Area of Residence 


















































Rural 
Urban 


14 5 
190 


■ 146 
191 


• 153 
177 


■0 


169 
169 


18,1 
168 


• 17,5 " 
16,1 ° 


10 9 
138 


• 106 
137 


• 98 
13,1 


ab 


132 
137 


13,7 
139 


130 
136 


142 
144 


137 
14,6 


" 131 
134 


b 


109 
144 


" 11 2 
140 


' 105 " 
129 t 


129 
146 


' 129 
146 


140 ' 


ALL BENEFICIARIES 


189 


19,0 


17,7 


b 


16 9 


169 


162 ° 


134 


13,2 


12 6 


_ 


13,6 


139 


13 5 


143 


14 1 


132 


b 


119 


120 


11,2 ■- 


14 1 


14 1 


13 5 ' 



• agnldcinlly diflersnl from the compaHson group at tha 0,05 l«val, 
" Signllicanllj dittoranl from 1991 10 1993 al Iha 05 level, 

SOURCE CHER analysis of Medicare Part B claims and deiKjmliiator file for a sample of beneficianes. 



ntij'itdnaVfinai/pIVjiaijnji £;\!dtnt-i a^.'h.* : 



TABLE C-6 

CONSULTATIONS BY EXPECTED MPS PAYMENT CHANGE AREAS AND VULNERABLE POPULATION GROUPS, 1991-1993 (age - sex adjusted consults per beneficiary) 





Vulnerable 














EXPECTED MPS PAYMENT CHANGE AREAS 






















Reductlor 


^ 




























Increase 








^^ 


























^ 






PoDUlation 




1 






2 






3 






4 






S 






6 




ALL AREAS 




1991 


1992 


199? 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 




Shortaqe Areas 














































All Shortage Combined 

Urban 

Rural 
Non-Shortage 


0.51 • 
0.51 
0.21 • 
52 


072 
072 
20' 
0.71 


0.68 * 
69' 
0.15* 
71 » 


37 • 
38' 
33* 
040 


50* 
51 • 
46* 
057 


51 * 
53 «■ 
044 » 
57 » 


52 • 
0.56' 
24« 
044 


68 • 
074* 
0.35 • 
60 


71 ' 
77 " 
34 " 
61 » 


39 • 
0.47 • 
26 ■ 
42 


56 
67 • 
37 • 
58 


56 » 
66 " 
39 " 
58 ' 


0.35 
48 ■ 
0.30' 
0.35 


0.48 
0.60 ■ 
0.42 " 
49 


48 « 
0.63 ' 
0.41 " 
0.50 ' 


0.32 • 
0.35" 
030 
30 


0.47 • 
0.54- 
043 
42 


67 "' 
52 •' 
44 ' 
42 ' 


41 • 
49 • 
28- 
40 


56 
67 • 
0.40 ' 
056 


57 ' 
68 ' 
40 * 
0.56 ' 




Poor Areas 














































All Poor Combined 

Urtjan 

Rural 
Non Poor 


77 • 
078 • 
23 • 
50 


0.99 • 
1.01 • 
0.28 • 
69 


1 01 «■ 
1.03 » 
25" 
0.69 » 


039 
0.40 
0.28' 
40 


59- 
0.60' 
054 
57 


58 » 
0.59' 
0.46 * 
0.57 » 


55 • 
0.60 • 
26 • 
43 


72 • 
77 • 
40 • 
0.59 


73" 
079 « 
40 " 
60 • 


49 • 
53 ■ 
25 • 
41 


71 " 
77 ' 
35' 
57 


71 ■«> 
77 ■» 
39 «> 
57" 


37 ' 
44 ■ 
26' 
35 


56- 
64 • 
43 • 
0.49 


55 « 
0.64 ■» 
0.42 « 
0.50 ' 


30 
31 ■ 
29 • 
030 


0.42 
0.47 • 
041 • 
42 


43' 
48 «■ 
0.42 ' 
42 ' 


48 « 
54 • 
27 ' 
40 


67 • 
074 ' 
40' 

055 


67 * 
075 •«■ 
0.41 »- 
55 ' 




ftaces 














































Black 
White 


054 
054 


079' 
74 


079 «> 
74» 


38 • 
40 


60* 
057 


0.61 «■ 
58 » 


54 • 
44 


071 ■ 
60 


71 « 
61 ' 


46 ■ 
42 


67 • 
58 


67 » 
58" 


42 • 
036 


56 • 
49 


0.58 » 
0.50' 


29 • 
31 


41 • 
43 


43 ' 

43' 


45 ' 
41 


63 • 
56 


64 ' 
56 " 


(1 

1 


Medicaid Eligible 














































Yes 
No 

Disabled 


0.79 ■ 
48 


1 07 • 
0.66 


1 10 » 
65» 


57 • 
038 


0.85' 
54 


56 » 
54" 


0.69 ■ 
41 


93 • 
0.56 


95 " 
57 ' 


59« 
40 


82° 
56 


83 » 
55" 


50 ■ 
34 


69 ' 
47 


71 » 
0.47 » 


44 ■ 
028 


59 ' 
40 


59 •' 
40 ' 


59* 
38 


82 ' 
53 


83 « 
53 ' 




Yes 
No 


071 • 
0.50 


1.02' 
0.68 


1.01 * 
68» 


55- 
038 


081 • 
0.54 


82- 
55- 


63 < 
042 


86 • 
57 


86 * 
0.58 ' 


57 ' 
40 


82 • 
56 


80 "' 
55' 


51 ' 
034 


70 ' 
47 


0.70 " 
47 ' 


42 ■ 
0.28 


0.58 ' 
40 


0.57 * 
40 ' 


56 • 

39 


79 - 

54 


76 ■« 

54 ■ 




Aus 














































85+ Years 
Less than 85 


0.68 • 
0.51 


1 00" 
0.70 


97* 
70 » 


49 • 
0.39 


073' 
056 


69"' 
57' 


57 • 
044 


077 • 
60 


80 "^ 
61 ' 


0.56' 
041 


0,80" 
0.58 


77 •» 
57 » 


40 • 
35 


56 • 
049 


0.54 «• 
50 » 


34- 
30 


47 • 
42 


48 •' 
42 ' 


51 • 
40 


72« 
56 


71 - 
50 ' 




Area of Residence 














































Rural 
Urban 


0.23' 
0.53 


0.31 • 
072 


0.33 « 
0.72 " 


33- 
40 


50* 
058 


0.52 •» 
58» 


0.27 • 
48 


39- 
065 


40" 
65" 


28 • 
46 


39' 
64 


40 " 
63 ' 


0.31 • 
40 


0.43 ■ 
054 


43 "' 
0.56 ' 


29 ■ 
33 


41 • 
045 


41 » 
46 ' 


29 • 
45 


0.41 • 
62 


42 ■" 
62 ' 




ALL BENEFICIARIES 


052 


0.71 


0.71 " 


040 


057 


0.57 ' 


044 


0.60 


0.61 » 


42 


58 


58' 


035 


049 


50' 


030 


042 


43 ' 


40 


56 


56 '■ 



• SIgrtflconlly different from Itie comparison group al lUe 0.05 level. 
» Signiricanlty different from 1991 to 1993 at the 0.05 level 

SOURCE: CHER analysis of Medicare Part B claims and denominator file for a sample of beneflclanes. 



montanaVina^pIVipr.iix-tMarjlfjs «liv ' i,r.i 



TABLE C-7 

NURSING HOME VISITS BY EXPECTED MPS PAYMENfT CHANGE AREAS AND VULNERABLE POPULATION GROUPS, 1991-1993 (age - sex adjusted visits per tjenefciary) 



Vulnerable 
Population 



EXPECTED MPS PAYMENT CHANGE AREAS 



Reduction 
1 



1991 1992 



1993 



1991 1992 1993 



1991 1992 



1993 



1991 1992 1993 



1991 1992 1993 



"^ Increase 
6 



1991 1992 1993 



ALL AREAS 



1991 1992 1993 



Shortage Areas 

All Shortage Combined 

Urban 

Rural 
Non-Shortage 



0.31 • 27 32 • 

32* 27 0.30' 

28 0.30 1,52* 

25 26 26 



30 • 31 • 32 ' 

33 • 0.34 • 0.36 " 

21 ■ 20 • 20 ■ 

26 28 31 ' 



37 • 39 • 42 ' 

0.39 • 42 • 45 ' 

0.23 • 22 • 21 ' 

33 0.35 38 ' 



0.29 ' 33 • 35 •» 

32 38 40' 

24" 24" 0.26' 

34 37 40 » 



0.27 • 28 ' 29 ■» 

0.27 • 30 • 31 •' 

26 • 0.27 • 28 ' 

31 34 36 » 



0.25 • 0.28 28 ' 

19 • 0.24 • 27 ' 

29 • 0.31 ' 29 

27 28 30 ' 



30 33 35 ' 

34 • 37 • 40 ' 

25 • 25 ■ 26 ' 

31 34 36 



Poor Areas 

All Poor Combined 

Urban 

Rural 
Non Poor 



36 • 35 • 38 ' 

0.37' 36" 38' 

05 ■ 14" 36 ' 

24 26 25 



42 • 45 • 46 «■ 

43 • 0.45 • 46 ■» 

0.35 • 37 • 43 "■ 

26 27 30 ' 



40 • 44 ■ 48 ' 

43 ■ 47 ■ 51 ' 

24 • 27 ■ 29 ' 

0.32 34 0.37 ' 



40 • 46 • 52 " 

42 • 49 • 56 " 

27 • 31 • 35 "■ 

33 36 38 ' 



33 • 0.36 • 38 "■ 

36 • 0.40 • 0.43 •« 

28 • 30 • 0.31 " 

31 33 0.36 » 



23' 24" 25' 

15 ■ 18 • 18 ' 

26 ' 26 • 0.27 ' 

0.27 29 31 ' 



38 • 42 • 46 " 

41 • 46 • 50 •" 

26 • 29 • 31 "° 

31 33 35° 



O 
I 



Races 



Black 
White 



Medicaid Eligible 

Yes 
No 



47 • 49 ■ 48 • 
26 26 27 



1,27' 1.28* 127- 
10 0.11 0.11 



39' 43* 46" 
26 0.28 30 » 



1.64 • 166' 1.74* 
012 013 014" 



0.J8 • 43' 47* 
34 36 38 ' 



1 59 ■ 1 68 • 1 78 ' 
018 019 0.19' 



40 " 47 • 51 * 
0.34 37 39" 



1 48 ■ 1 60 • 1.72 " 
23 26 26 



33 38 • 42 "■ 
0.32 0.34 0.36 » 



27 
028 



29 
0.29 



32 ' 
31 ' 



1 61 ■ 


1 71 • 


1 91 * 


1 21 • 


1 23 • 


1 24 ■ 


019 


20 


0.19 


012 


13 


14 " 



0.37 ' 
32 



J 42 ' 46 ' 
34 36 ' 



1 51 • 1 58 ■ 1 69 "■' 
18 20 20° 



Disabled 



Yes 
No 



45 • 0.52 • 55 ■> 
0.23 0,24 023 



48 • 0.52 ' 0.55 * 
24 26 28 » 



63" 69* 69* 
30 32 34° 



58" 0.68' 73" 
31 34 36 » 



52 • 


59 ■ 


63 " 


39 • 


43 • 


45 •" 


29 


30 


0.32° 


0.25 


26 


0.28 ° 



55 ■ e^ ' 65 ' 
29 31 33' 



6aa 



85+ Years 
Less than 85 


2.05 • 
020 


2 04' 
021 


1.94* 
0.21 


Area of Residence 








Rural 
Urban 


0.10 • 
25 


0.14' 
026 


0.15 * 
0.26 


ALL BENEFICIARIES 


0.25 


026 


0.26 



2 13' 2.19' 2.17* 
0.22 0.23 25 " 



21 • 22 • 24 * 
27 29 0.32 " 



2 28 ■ 2.42 • 2 38 * 
28 0.29 0.31 ° 



27 ' 0.29 ■ 30 * 
34 37 0.40 ° 



2 43 ■ 2 69 ' 2 69 * 
28 0.30 0.32° 



2 22 • 


2 39 • 


2 40 * 


1.89 • 


1 98 • 


1 94 •' 


0.26 


027 


29° 


22 


0.24 


25 ' 



27 ■ 


30 • 


31 * 


31 


0.34 


36 


35 


39 


42 ° 


31 


33 


35 



0.26 0.28 0.31° 33 0.35 0.38° 33 0.37 39' 



31 



0.28 • 30 • 31 * 
23 25 27 » 



0.33 0.36° 0.27 28 30' 



2 26 ■ 2 43 " 2 42 ' 
23 28 29 ' 



28 • 30 • 32 ^ 
32 35 037" 

31 34 30 ° 



NOTES: 

■ Slflnlficanlly dlfteronl from the connpanson group at lh« 0.05 level. 
» Significantly dlferenl from 1991 to 1993 at Itw 0.05 level. 

SOURCE: CHER analysis ol Medicare Part B claims and denominator nie (or a sample of benetlcianes. 



inonlar(a'Jiiiali|j|\at.p)u(.L\luO(i-, /I . v /v 



TABLE C-8 

PNEUMOCOCCAL PNEUMONIA VACCINATIONS BY EXPECTED MPS PAYMENT CHANGE AREAS AND VULNERABLE POPULATION GROUPS, 1991-1993 (age - sex adjusted services per 1.000 beneficiaries) 











EXPECTED MPS PAYMENT CHANGE AREAS 






























^ 


Increase 
6 




Vulnerable 
PoDulatlon 


Reduction ^ 
1 


2 




3 4 




5 




— ^ 


ALL AREAS 


1991 1992 1993 1991 


1992 


1993 


1991 1992 1993 1991 1992 1993 


1991 


1992 


1993 


1991 


1992 1993 


1991 1992 1993 



Shortage Areas 



n 
1 

00 



All Shortage Combined 

Urban 

Rural 
Non-Shortage 


19.9' 
20 1 • 
48* 
21.9 


16 9* 

17 2' 
02* 

22 9 


26 6 * 
26 8- 
16 8" 
35 3' 


14 2' 
14 9 • 
12 2 • 
24 1 


132 ■ 
140" 
10 8' 
22.8 


20 8 " 

21.6 " 
134 •» 
41 9' 


138 • 
12 5 ■ 
220 
23 3 


11.4' 
106 • 
162 • 
20 2 


17 7 " 
16 " 
27 8 " 
35 4' 


386 
162 • 
77 8 • 
36 9 


34 
18.0 
61 1 
41 8 


46 9 
33 9 " 
69 

60 5' 


143 9 • 
399 6 • 

25.8 • 

78 2 


104 9 ■ 

280.0 ■ 

25 2 ' 

65 4 


74 ' 
1528' 

38 5 " 
102.3 


23 7 ■ 
195 • 
26 0' 

24 7 


18 3 • 
186 • 
182 • 
21 5 


34 6 " 
31 7 •» 
36 1 " 
41 6 ° 


54 3 • 
61 1 • 
43.3 
38 1 


42 4 
46 6 

35 9 

36 3 


43 2 « 
40 6 " 
47 2 ■ 
57 4 ' 


Poor Areas 












































All Poor Combined 

Urban 

Rural 
Non Poor 


98- 
9 7 ■ 

17 • 

226 


56" 
5.6 ■ 
63' 
23 8 


122 •» 

12 3* 

5 6 " 

36 3' 


140 • 
13.9 • 
148 • 
242 


13 2* 
129 • 
164 • 
22 9 


23 4'' 
22 8 "> 
31.1 " 
42 0' 


137 • 
121 • 
23 9 
238 


106' 
10 1 • 
134- 
207 


18.1 " 

15 6 •» 

326 6 " 

36 2' 


14.5 • 
130 • 
23 2 
39 


129 ■ 
123 • 
164 
43 8 


23 8 " 

22 8 " 
29.7 " 
62 8' 


626 
91 8 
18 6 • 
837 


36 1 • 
48.4 
17.9 • 
69 5 


61 6" 

80.5 
34.6" 
102 1 


18 8' 
12 1 • 
21 1 ■ 
25 1 


15.8 ■ 
12 1 • 
17 • 
21 8 


29 1 ■' 
21 7 " 
31 6 " 
42 3 ' 


195 ■ 
190 • 
21 6 • 
40 5 


147 ■ 
142 • 
152 • 
38 4 


26 « 
24 4 • 
31 8 "' 
59 0» 


Races 












































Black 

White 


99" 
22 2 


11 9 ' 
24 1 


14 1 ^ 
37 9' 


11 • 
25 2 


109 • 
23t) 


15 6" 
43 9 ' 


11.8 • 
24.4 


96 ■ 
21.2 


14 6" 
37 3 ' 


144 ■ 
40.1 


149 
45 J 


22.1 " 
64 7 ' 


101 8 
82.1 


683 
70.4 


80 1 
105 4 


13.0 • 
26 3 


10 2 " 
22 7 


18 5 ■» 
44 3 - 


27 5 ' 
40 7 


21 3 • 
39 2 


28 A • 
GO 'J " 


Medicaid Eliaible 












































Yes 

No 


11.8' 
234 


14.0 • 
24.1 


14.9'' 
38.1 ' 


14.0 ■ 
248 


121 • 
236 


20.2 " 
43 5 ' 


15 2* 
237 


10 7 • 
20.8 


20 4" 
36 3' 


24 4 
38 1 


25 3 
42 8 


32 9' 
62 4' 


33 7 ■ 
874 


22.3 • 
726 


38 2 • 
106 9 


177 ■ 
258 


152 • 
22 3 


25 9" 

44 ' 


20 9 • 
40 9 


1 7 6 ■ 
38 7 


27 4 •' 
6u 1 » 


Disabled 












































Yes 
No 


15.9 ■ 
224 


15.1 • 
234 


23 4" 

36 1 ' 


18 0' 
243 


16 9 • 
23 


28 " 

42 6' 


17 7 • 
23 4 


134 • 
20 4 


24 9 " 
35 5' 


30.1 
37 7 


31.2 
42 4 


48 ' 
61 ' 


580 
857 


38 7 • 
71.5 


65 6 • 
1045 


19 1 • 
25 4 


16 1 • 
22 1 


30 " 
43 ' 


29 6' 

40 


24 9 • 
37 9 


•11 2 •' 

58 4" 



Age 



85+ Years 
Less than 85 


16.1 • 
220 


204 
229 


22 4 " 
35.5' 


16.5 • 
239 


17 9 • 
22.6 


32.3' 
41 4 » 


15.0 • 
23.0 


14 0- 
19.9 


22.8 " 
34.8' 


22 3" 
37.4 


26 1 
41.8 


33.1 
606 


Area of Residence 


23 8' 
21 8 


16.7 ■ 
230 


19.1 " 
35.6' 


245 
23.6 


21 2 
22.7 


40.3 " 
41 3 ' 


27.1 • 
21.9 


192 
19.8 


37.5 " 
33 8' 


59 1 ■ 

30 7 


55 3 
374 




Rural 
Urban 


86.4 
52.2 


^LL BENEFICIARIES 


21 9 


228 


35.1 ' 


23 7 


225 


41.2 ' 


22 8 


197 


34 4 ' 


37.0 


41 3 


59 7 







46 6' 43 0' 34 3" 
83.8 68.9 1026 



82 8 68 1 100 4 



15.2' 14 7* 25 8" 
24 9 21 5 41 8 ' 



23 7 ■ 24 4 ■ 29 8 ' 
39 3 oJQ 57 5' 



ID 


248 


20.5 • 


40 " 


347 


30 9 


52 6 " 




24.5 


23 3 


44.5 » 


40 6 


38 9 


58 1' ' 




24.7 


21 4 


41 3 ' 


38 9 


36 7 


56 (. " 



• significantly diffefert from tlie compailsoo group at the 05 lovol. 
» Significantly different from 1991 to 1993 at the 0.05 level 

SOURCE: CHER analysis of Medicare Part B claims and denominator file for 8 sample of t>enetlcianes 



fnDfilrtndyiritilrpt\iipprix-(,M>iLlci 



TABLE C-9 

COINSURANCE LIABILITY BY EXPECTED MPS PAYMENT CHANGE AREAS AND VULNERABLE POPULATION GROUPS. 1991-1993 (age - sex adjusted per beneficiarY) 



Vutnarable 
Population 



1991 



Raductlon 
1 



1282 



1993 



EXPECTED MPS PAYMENT CHANGE AREAS 



1991 



1992 



1993 



1991 



1992 



1993 



1991 



1992 



1993 



1991 



1992 



1993 



laSl 1292 12S3 



1991 



19M3 



Shortaaa Ar»«» 



Al Shortage Combined 

Urtan 

Rural 
NorvStKXiage 


$275.tj' 
27824 • 
9461 • 
290 96 


$24367 • 
246 00 • 
93 16 ■ 
259 32 


$222 32 - 

224.45 « 

94 88 ' 

247 47 « 


$216 46 • 
222 25 ' 
198 75 ' 
239 46 


$204.21 ' 
207 14 ' 
196 60 • 
22458 


$200 16 " 
203 01 • 
191 83 - 
21922 


$204.69 ' 
209 27 
17609 ' 
209 76 


$19126' 
19497 
168.99' 
198.33 


$182.66 '» 
18666 •• 
158.37 " 
193.88 ' 


$18385 ' 
191 99 
169 84 ' 
191.91 


$175 55 • 
132 94 
163 02 ' 
186.74 


$17626 ■» 
181.53 » 
167.37 
185 16 ' 


$178 10 ' 
208 68 ' 
163 97 ■ 
186.60 


$171.70 ' 
197 58 • 
15992 ' 
131.26 


$17017 '» 
201 56 '» 
156.05 " 
177 34 • 


$175,11 ' 
176.63 
174.28 ' 
178.38 


$17190 
174.82 
170.33 ' 
173 39 


$16976 '" 

171 21 ° 
16900 » 

172 56 " 


$191 35 • 
204.92 
169.69 ' 
203 19 


$18174 ' 
192 75 
164 46 ■ 
194 53 


$178 69 " 
188 57 *" 
16 18 " 
191 11 ' 


Poor Areaa 












































Al Poor Combined 

UrtMin 

Riral 
Non Poor 


428 10 • 
433 68 • 
10518 ■ 
282 34 


386 50' 
391 86 ' 
96 47 ■ 
251.63 


376 66 • 
38190 " 
100 03 • 
239 69 » 


224 50 • 
22377 ' 
233 16 • 
239 36 


21287 ' 
211.24 • 
232 07 ' 
224.40 


20667 •" 
2i;5 34 '» 
225 96 '" 
219.12 ' 


201.47 • 
202 90 ' 
192 83 ' 
21039 


189.31 ' 
190 49 ' 
182 32 ' 
198.90 


184 34 «■ 

185 26 •» 
178 97 " 
194 23 » 


189.73 
192 51 
173 23 ' 
19160 


183 08 

184 60 
174 27 • 
186 35 


183 98 « 
185 60 » 
175 32 • 
18469 » 


194 72 • 
191 44 • 
199 70 • 
184.66 


190.92 ' 
185 03' 
199 60' 
180.15 


190.39 " 
186.90 '» 
196 78 ' 
176.27 ' 


175.87 • 
169 92 ' 
177 84 
178.46 


170.23 ' 
162,76 ' 
1,268 
17369 


171 60 » 
165 33 "■ 

172 94 «■ 
17257 ' 


202 65 
207 34 • 
185 41 ' 
202.54 


19315 
196 30 ■ 
181 79 • 
193 89 


lai 10 ' 
194 03 " 
180 74 " 
190 40 " 


Races 












































Black 
Wtiite 


284 68' 

30143 


255 48 ' 
26867 


238 67 » 
258.94" 


217 22 ■ 
243 78 


207 63 ' 
228 12 


203 81 '• 
222 76 ' 


209 73 
212 97 


197 44 
200.91 


192 84 • 
195 20 • 


184 90 ' 
195 27 


178 77 ' 
18909 


180 64 ' 
187.04 ' 


199 31 ' 
187 20 


192 60' 
181.64 


193 08 * 
177.36 » 


155 52 ' 
183 75 


154 08 ' 
177 27 


158 46 -^ 
175 57 ' 


195 45 ■ 
206 55 


187 40 ' 
196.95 


186 60 '■ 
19:' 91 ' 


M^lrald Eligible 












































Yes 

No 


412 48 • 
272.52 


375.B7 ' 
241.86 


3f 1 27 " 
229 62 » 


299 82' 
232.07 


28307 • 
217.33 


1.5 94 " 
2:1.94 » 


27486 
20137 


262.23 ■ 
189.84 


266 67 » 
184 92 • 


235 96 

187 40 


230 33 ■ 
182.01 


228 72 "■ 
180 30 » 


23424 ' 
180 40 


231.48 • 
17566 


231 68 ' 
171 11 » 


219.70 ■ 
171.84 


21747 • 
166.31 


213 90 " 
166 38 ■■ 


260 22 
196.29 


250 62 ' 
IB/ 57 


246 :.'!i '" 
183 89 ' 


Ciubiad 












































YM 

No 


36S 22 ■ 
283.81 


330 69 ' 
25270 


314 26 » 
240.74 » 


289 26- 
233.32 


273 27 ' 
21882 


266.61 - 
213.47 ' 


266 91 
204 02 


24541 ■ 
192.6b 


239 98 " 
187 82 ' 


23211 
186.92 


230 23 ■ 
181 34 


224 54 " 
18017 • 


227.47 • 
180.10 


224 05 ' 
176 63 


21963 " 
171 76" 


207 63 
174 24 


203 50 ■ 
169 30 


204 50 » 
157.93 ' 


244 73 
197 75 


237 49 • 
189 02 


232 36 •' 
18^62 ■' 


6aa 

i6* Years 
Less than 85 


334 95 • 
289 35 


301 62 ' 
257 71 


288.07 " 
246.51 « 


247.94 
238.40 


235.00 
22354 


225 04 ■" 
218 34 ' 


218.70 
209 20 


208.76 
19761 


203 19 «■ 

192.92 • 


202 15 
191 14 


201 57 ■ 
185.64 


199 10 ' 
184 16 » 


183 73 
185.12 


18299 
180.53 


179.26 !■ 
17677 » 


176.43 
17832 


178 22 ' 
173 21 


176 22 • 
172 35 ' 


21043 
202 33 


205 29 
193 51 


200 78 "^ 
190 11 ■■ 


Area of Reildeacs 












































Rural 

Utt>an 


146 24 ■ 
295.30 


133.51 
26312 


134 46 - 
250 70 » 


22437 
24078 


216.44 
225 04 


216.60 " 
218 96'' 


195 86 
212 18 


138 03 
199 92 


183 22 " 
19526 » 


177.33 
196 42 


173 63 ■ 
189.64 


171.51 ■ 
188.34 ° 


17561 
19366 


171.22 ' 
18910 


16908 " 
183.85 ° 


176 68 
184 54 


17164 
177.43 


171 22 '- 
175 43 '■ 


181 30 
210 79 


176 27 
200 65 


1 74 i 1 ■" 
196 OS ' 


Al 1 BENEFICIARIES 


290.55 


258 92 


246.84 ' 


23863 


22384 


218.63 ' 


209 46 


197 93 


193.25 « 


191 44 


186 09 


13464 » 


185 09 


180.60 


17685 » 


178.27 


173.34 


172 47 « 


202 55 


193 84 


190 4S ■■ 



SlgnmciWy ailt»r«r« tron. »>• comp.plf»i v^ « ih. OS l.v«l. 
• Sljn»lc«nll» a««onC tran 1991 10 1SS3 •! "» 0.05 UM. 

K>U«ei: 0« -»^ - M-C". PI 8 1*" •""^"*"" "'•*"""'" """'""**'■ 



TABLE C-10 

EXTRA BILLING LIABILITY BY EXPECTED MFS PAYMENT CHANGE AREAS AND VULNERABLE POPULATIONS GROUPS, 1991-1993 (age - sex adjusted per benefi' lary) 



O 
I 

















1 


EXPECTED MFS PAYMENT CHANGE AREAS 














1991 


ALL AREA! 

1992 








Reduction 
1 




























► 


Increase 
6 






Vulnerable 
Population 


■^~ 




2 






3 






4 






5 


1 


3 


1991 


mz 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1993 


Shortage Areas 












































All Shortage Combined 

Urban 

Rural 
Non-Shortage 


$20 46 ■ 
20 16' 
4185 
4325 


$13 96 ■ 
13 77 ■ 
25 78 
24 65 


$497 • 
4 85" 

12 40' 
9,76' 


$21,34' 
17 93' 
31 78' 
41 12 


$1346 • 
1018' 
23 20 ' 
26,05 


$6 36" 
4 51 " 
1173' 
1209° 


$16 54- 
12 93- 
38 53 ' 
33 26 


$10 62' 
7 83' 
' 27 31 ' 
20 63 


$5 47 » 
400" 
1413" 
10 36' 


$24 61 ' 
18,09 ■ 

35 82 

36 55 


$15 86' 
1102' 
24 07 
2418 


$8 65 " 
5 36" 
14 19" 
12 39' 


$34,93 ■ 
17,03' 
43 19 ' 
36 24 


$25 09 
11.65 • 
31,21 • 
2459 


$13,34 " 
6,94" 
16 21 " 
12 52' 


$27,52 ' 
3165' 
25 25- 
38 31 


$1561 ' 
18 91 ■ 
13 83- 
23 29 


$8,35 " 

10 12 » 
7 42" 

11 29' 


$24 88 ' 
16 67 ■ 
37 99- 
36 70 


$16 52 • 
10 26 • 
26 35 * 
23,59 


$8 72 ^ 
5 15 X. 
14 26 « 
11 71 


Poor Areas 












































All Poor Connbined 

Urban 

Rural 
Non Poor 


9 09" 
9,03 • 
12,55 ■ 
44 65 


486' 

4,80* 
8 32* 
25 50 


218' 
218- 
2 56" 

10 05 ' 


17 40 ■ 
17 92' 
11 19' 
4160 


10,32 ' 
10,45 ' 
889' 
26 37 


460" 
4.70" 
3 30" 
12.25' 


13 40' 
1218' 
20 82' 
34 49 


7 80 ■ 
' 7 20' 
' 1131' 
21 44 


4 09" 
3 87" 

5 39 " 
10,75' 


1781 • 

17 72 • 

18 38 ■ 
37 48 


11 33• 
1153• 
10 17 ' 
24 78 


6 46" 

658" 
5 76" 
12 70' 


1556- 
1289 ' 
1961 ' 
37 07 


1042 • 
7 99' 
1401 ■ 
25 25 


5 20" 
3 81 " 
7 17" 
12 89' 


2183' 
2274 • 
21,52 • 
39 23 


12 40- 
13,60' 
1200" 
23 87 


617 " 
7 49 " 

5 73" 
11 59 ' 


16 21 ' 
15 22' 
19 88' 
37 66 


9 93 • 
945 - 
' 1 1 &8 • 
24 26 


5 28 .0 
5 11 « 
5 68 « 
1203. 


Rac— 












































Black 
White 


911 ■ 
4645 


4 62 ■ 

26 81 


159 " 
10 54 • 


11 73' 
43 59 


690' 
27 62 


2 93 " 
1281 ' 


9 62' 
35 46 


5 54' 
22 05 


2 78" 

11 3' 


1060' 
38 97 


6 59' 
25 64 


3 15" 
13 23' 


9 60' 
38 95 


5 35' 
26 49 


2 39" 
13 49' 


1218' 
si, 69 


7 07 ' 
25 18 


3 75" 
12 20' 


10 43 ■ 
39 23 


6 16 • 
25 2: 


2 94 ^ 

1 7 5^ . 


Medicaid Ellalble 












































Yes 
No 


373- 
4841 


1 90- 
27,66 


69" 
1100' 


5 65' 
44 14 


291 • 
2808 


132" 
13 10' 


4 52' 
35 74 


2.41 ' 
22 28 


111" 
11 28' 


6 44' 
38 53 


3 57- 
25 55 


156" 
13 22' 


7 42' 
38 89 


3,75' 
26 65 


2,11 " 
13 68' 


6 76' 
42 79 


3 79' 
26 11 


1 63 " 
12 83' 


591 ' 
39 34 


317 
25 43 


1 47 ^ 
12 /3 . 


Disabled 












































Yes 
No 


35 10' 
43 33 


' 19,28 ■ 
24 82 


6 35" 
9 94' 


3002 ■ 
4150 


18 15' 
26.35 


8 04" 
1229' 


22 90' 
33 38 


■ 13.50 ' 
20 79 


6 43 " 
1051 ' 


2810' 
36 72 


18 19' 
24 29 


8 63" 
12 57" 


28 90 ' 
37 00 


18,47 ' 
25 33 


9 04 " 
13,00' 


29,88 • 
39 06 


17 55- 
23 77 


8 05 " 
11 64 » 


27 66 ■ 
37 02 


■ 17 13' 
23 89 


8 00 » 
11 96 a 


Bat 












































85+ Years 
Less than 85 


35 85 ' 
42 83 


' 20 68 • 
24 48 


9 22" 
9 66' 


35 69- 
40 53 


23 42' 
25 65 


11.09" 
1191 ' 


26 94' 
32 45 


' 17.68 ' 
20 13 


8 89" 
10 12' 


30 88 ■ 
36 00 


21 13' 
23 77 


1 1 38 " 
1220' 


30 79' 
36 30 


20 71 • 
24 74 


10 64 " 
12 64 ' 


32 71 • 
38 09 


20 81 ■ 
23 10 


10 41 " 

11 22' 


30 79 
36 21 


• 20 44 • 
23 29 


10 46 .1 

1 1 ■:.& . 


Area of Residence 












































IRural 
Uftxn 


25,18 ■ 
43,22 


' 15.15' 
2469 


7,69" 
9,71 • 


40,34 
4042 


26.03 
25.53 


12.22 ' 
1183' 


37.26 ' 
31.31 


' 22 76 ' 
19 52 


11,46 " 
981 ' 


38 98 ' 
34 98 


27 04 ' 
22 75 


13,82 " 
1172' 


44,49 • 
28 60 


3199 • 
17 95 


16 66" 
8 90° 


34 12- 
47 22 


20 80' 
28 40 


9 86" 
14 39 ' 


39 40 

34 77 


■ 26 51 • 
21 94 


1 ;; 39 .. 

10 64 , 


ALL BENEFICIARIES 


42 65 


2438 


964' 


40,41 


2559 


1188' 


32 30 


20 06 


10 08' 


35 86 


23 70 


12 18 ' 


36 15 


24 63 


12 58' 


37,95 


23 04 


11 20 ° 


36 06 


23 21 


11 55. 



• Signiflcanlly difforenl from lh« comp«nson gf(i«jp ■! the 0.05 l»™i 
° Signl(lc»nlly dlfferenl from 1961 to 1983 >t the OOS lev«l. 

SOURCE. CHER .nalysl. o( Madicir. P.tt B claims .nd d«»mm.tor file for • sample of beneildanes. 



(lion[drid\linalrp(\dt,pi ir i \ | .itji^- 



TABLE C-11 

ASSIGNMENT RATE BY EXPECTED MFS PAYMENT CHANGE AREAS AND VULNERABLE POPULATION GROUPS, 1991-1993 (age - sex adjusted per beneficiary) 



n 
1 

























EXPECTED MFS PAYMENT CHANGE AREAS 




















ALL AREAS 








Reduction 
1 


■* 










































Increase 
6 






Vulnerable 
PoDUlatlon 


V 




2 








3 










4 










5 




W 




1991 


1992 




1993 




1991 


1992 


1993 




1991 


1992 




1993 




1991 


1992 




1993 




1991 


1992 


1993 




1991 


1992 


1993 


1991 


1992 


1993 




Shortage Areas 






























































All Shortage Combined 

Urban 

Rural 
Non-Shortage 


72.0% 
72 4 
476 
72.1 


740% 
74.0 
• 520 
75 


> 


715% 
71 7 
59.1 
766 




69 5% • 

71.2 • 
643 ■ 
672 


72 7%' 
742 ■ 
683 • 
712 


75 5% 

76 3 
73 3 
763 


D 

ac 

D 


68 7% 
699 
619 
667 


• 709% 

■ 71 8 

■ 660 
707 


• 


729% 
73 4 
70 
753 


Ob 

ac 
b 


67.5% • 
70 5 • 
62 2 ■ 
64 1 


71 3% 
741 
66 6 
68 7 


• 


75 3% 
77 3 
718 
74.5 


ab 
ab 
ab 
b 


62 9% • 
725 • 
584 « 
63.9 


66 9% a 
75.0 • 
63,3 ■ 
685 


73 3% 
77 7 
71,3 
75 


at. 
ab 
ab 

t 


65 4% . 
621 • 
67 2 • 
605 


70 6% • 
66 6 • 
72 7 a 
66 


74 1% ab 

70 9 " 

75 8 "b 
72 4 ■ 


66 8% 
70 4 
61.2 
65 


< 70 3% ' 

• 73 2 • 

■ 65 8 « 

69 4 


74 1% 
756 
71 9 
74 9 


db 
al. 


Poor Areas 






























































All Poor Combined 

Urban 

Rural 
Non Poor 


83.9 
843 

577 
71.4 


• 840 

• 840 
■ 600 

75 


• 


810 
812 
653 
763 




713 • 
708 • 
772 • 
671 


743 • 
739 • 

796 • 
71 1 


770 
765 
83 7 
76 2 


00 

b 
b 


722 
72 8 
68 9 
66 2 


• 74 5 

• 74 7 

• 73 1 
70 2 


• 


767 

76 6 

77 1 
75 


ab 

ab 
ab 

b 


69 9 • 

69 8 ' 

70 7 • 
638 


72 9 
72 4 
75.5 
685 


• 


75 4 
74 9 
78.3 
745 


ab 
b 

ab 
b 


74 2 • 

75 5 ■ 
722 • 
633 


773 • 
781 a 
76 2 ' 
680 


80,8 
81 1 
80,4 
747 


ab 


68 1 • 
634 • 
696 • 
60.1 


72 6 a 
67 2 ' 
74.4 • 
65.7 


76 5 «- 
70 4 a^ 
78 4 « 
72 2 b 


71 5 
71 8 
70 4 
64 6 


a 74 3 ■ 

' 74 1 « 

• 74 8 « 

69 1 


76 8 
76 2 
78 6 
74 7 


rib 

al 


places 






























































Black 
White 


759 
72 


• 76 
760 


■ 


723 
770 


D 


726 • 
673 


75 4 • 
71.4 


77 8 
76 7 


Bb 


72 1 
66 8 


• 74 4 
70 8 




76 1 
75 7 


b 


71 7 • 
64 1 


74 4 
68 8 


' 


768 
749 


ab 
b 


75 1 a 
63 6 


781 ■ 
68 2 


810 
75.0 


6 


701 • 
60.1 


73 6 • 
659 


77 '" 
72 5 '• 


72 3 
65 


» 75 » 
69 5 


77 3 
75 2 


.« 


Medicaid Elidible 






























































Yes 

No 


90 7 
69 4 


. 908 
73 1 


• 


890 
746 


U> 


89 • 
65 


902 ■ 
692 


905 
746 


^ 


887 
64 1 


• 89 8 
683 




901 
73 2 


ab 


86 8 » 
62 3 


884 
670 


a 


897 
73.1 


ab 


88.6 ■ 
61.4 


90 6 ' 
66.2 


ri6 

73 2 


b 


884 a 
564 


90 2 • 
623 


90 8 * 
69 4 ■ 


88 2 
62 6 


« 89 7 ' 
67 2 


90 ?, 
73 


-Jb 


Disabled 






























































Yes 
No 


77 
717 


• 79 7 
750 


• 


78 7 
763 


D 


740 • 
666 


770 ■ 
70,7 


794 
75.9 


ab 

b 


732 
661 


■ 76 4 
70 


a 


79.2 
74 7 


ab 
b 


71 1 a 
63 5 


74 7 
68 2 


e 


78 4 

74 1 


ab 
b 


709 • 
63.0 


75 • 
67 6 


797 
743 


ab 


680 • 
59 7 


72 5 a 
653 


77 1 -^ 
718 1 


71 7 
64 4 


« 75 3 ' 
68 8 


78 8 
74-1 


t, 


Afls 






























































85+ Years 
Less than 85 


79.9 
71.9 


• 835 
75.2 


■ 


84.7 
762 




747 • 
67.1 


789 • 
71 1 


829 
76.1 


Mt 


75 7 
66 6 


• 796 
704 




82 9 
74 9 


ab 


723 • 
64 1 


77.1 
686 




815 
743 


ab 


719 • 
636 


77 • 
68 1 


82.0 
747 


ab 
b 


70.3 a 

60 4 


755 ■ 
659 


80 5 «b 
72 2 ' 


73 4 
64 9 


"77 9 ■ 
69 i 


Ui t 
74 6 


a. 


Area of Residence 


684 
722 


• 703 
77.5 


• 


73.5 
76.6 


■D 
D 


665 • 
674 


72 1 • 

71 1 


775 
76.1 


■C 


62 8 
676 


• 68 
712 


B 


733 
755 


ab 

b 


626 • 

64.8 


676 
692 


d 


737 
74.8 


ab 
b 


587 a 
68.4 


63,8 ' 
72,6 


721 
77.4 


ab 

b 


621 ■ 
57.3 


677 a 
62 5 


74 •' 
69 ■- 


61 5 
66 5 


' 66 7 ■■ 
70 5 


/3 4 
76 4 




Rural 
Urban 


:,b 


ALL BENEFICIARIES 


721 


75 4 




76 5 


D 


67.3 


713 


763 


b 


66 8 


70 7 


^^ 


75.2 


b 


643 


68 8 


■M 


74.5 


b 


638 


68 4 


74.9 


b 


607 


66 2 


72 5 " 


85 1 


69 5 


74 B 





a Slgnincanlly dm«r«nl Irom IM cwrjnrljon group at m. 0,06 l«v«l. 
a Si^flcanlly dl««r«nl from tSSI to 1963 at Ih. 05 lavrt. 



SOURCE: CHER analysis 



of M««oare Part B olalms and d«ion.natof HI. tor a sampl. al bweHolahas 



nii.iinand\ftiiulrplUifi[jMj lJjI.I^., «i^ii 



TABLEC-12 

CATARACT SURGERIES BY EXPECTED MFS PAYMENT CHANGE AREAS AND VULNERABLE POPULATION GROUPS, 1991-1993 (age - sex adjusted procedures per 1,000 beneficiaries) 



I 

















EXPECTED MFS PAYMENT CHANGE AREAS 














ALL AREA 








Reduction 
1 




























w 


Increase 
6 






Vulnerable 






2 






3 






4 






5 




W' 


S 




1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


Shortaqe Areas 












































All Shortage Combined 

Urban 

Rural 
Non-Shortage 


49.2 
496 
20.9' 
50 3 


45 • 
45 4* 
21 • 
49 3 


39 1 •" 
39 6- 
13.8 • 
45.3° 


43 2 • 
44.0 ■ 
40 6 • 
498 


48 8 • 

49 5 • 
46 9' 
526 


42 5' 
42 6 • 
42 2 ' 
51 3 


40.1 
398 
425 
41 1 


444 
44.0 
46 5 
465 


37.9 • 
36 2 ' 
47 7 ■" 
43.5 


388 

37 8 
406 

38 4 


41.8 
38.7 
47 1 ' 
423 


37.5 • 
34 4 ' 
42 7 
42 4° 


36 8 • 
403 
35 2' 
395 


38 8 ' 
39.6' 
38.5 ' 
44.6 


385 
39 4 
38 1 
404 


35 1 ■ 
31.2 ' 
37.2' 
41.1 


40 8 ' 
37 7 ' 
42 4 • 
464 


38 7 * 
36 7 ■" 

39 8 " 
44.4 ° 


39 ' 
39.5 ' 
38 2 ' 
41 3 


42 3 • 
41 8 • 

43 " 
45 5 


38 3 . 
36 6 « 

41 «■ 
43 6 .- 


Poor Areas 












































All Poor Combined 

Urban 

Rural 
Non Poor 


54.0' 
54 1 ' 

49 5 

50 1 


54 3- 
54 4 ■ 
50 5 
48 9 


50 9" 

51 1 «■ 
37.4 " 
44 8 " 


45 7 • 
42 8 ■ 
78 9 • 
49.8 


500 
48 5 • 
68 2 • 
52 5 


46 8 ' 
45 0'° 
67 9 * 
51 2 


38 3 . 
37 6 ' 
42 8 
41 3 


42 0' 
40 9 • 
48 8 
46 8 


38 4' 
36 8 ' 
47 7 " 
43.8 


35 3' 
34.1 ' 
42 8' 
38 7 


38 7 ' 
36 7 ■ 
50 ■ 
42.6 


36 1 ' 
33 8 ' 
49 5 " 
42.7 


42.9 ' 
39 8 
47 4 • 
392 


47.6 • 
45.2 
51 2' 
441 


45 2' 
42 2° 
49 4 ' 
40.0 


40 1 
40 1 

40 1 

41 


44 1 » 
39 8 ■ 

45 5 

46 4 


43 6 ' 
39 3' 
45 0° 

44 3 ' 


38 8 ' 
37 5 ' 
43 9 ' 
41 3 


42 5 • 
40 6 • 
49 1 • 
45 6 


39 / . 
37 3 . 
48 2 ^ 
43 6 ^ 


Races 












































Black 
White 


41 4 ' 
51 9 


39 4- 

51 1 


30 6 * 
46 7 » 


38 8' 
51 1 


43 6 ■ 
542 


39 1 " 
527 


35 7 • 
42 3 


36 5 • 
48 2 


33 7 • 
44 8 


31 5 ' 
39 7 


32 7 ' 
439 


30 9 ' 
437 


35 1 ' 
40 7 


37 4 ■ 
45.5 


348 ■ 
41.1 


28.2 • 
42 9 


35 7 • 
47 9 


34 « 
45 9 ° 


33 7 " 
42 6 


36 " 
47 


33 4 . 
44 8 


Medicaid Ellqible 












































Yes 
No 


55 3 • 

49.5 


52 0' 
488 


48 9 » 
44 6" 


51 1 • 
49 4 


55 5 ' 
52 1 


50 3 

51 1 


44 8 • 
40 6 


48 9 
46 


44 3 
43 1 


408 
38 2 


43 3 
42 2 


42 2 
422 


43 2' 
390 


47 4 • 
439 


44 4 • 
39.8 


43 5 ' 
40 5 


49 3 • 
457 


46 7 "^ 
43 8 ° 


44 5 • 
40 8 


47 9 ■■ 
45 


44 & . 
43 2 L 


Disabled 












































Yes 
No 


38 2' 

51 4 


40 0' 
500 


33 4* 
46 2 ' 


37 2' 
50 8 


42.7 ' 
53.4 


37.5 ' 
52 4 


30 9 ' 
42 2 


34 3' 
47 7 


32 4- 
44 5 


28 7 ■ 
39 5 


33 4' 
43 2 


31 3" 
43 4 


30.1 • 
404 


34 8 • 
45 3 


32 1 • 

41 2 


29 2 • 

42 5 


32 6 ' 
48 1 


31 3 "' 
46 ° 


30 7 • 
42 3 


35 U ' 
46 5 


32 4 -. 
44 6 . 


Aflt 












































85+ Years 
Less than 85 


59 6* 
50.0 


56 9 ' 
490 


52 2"' 
44.9° 


60.3 • 
49.3 


60.8 • 
522 


49.9° 
510 


51.1 ' 
40.7 


52 9' 
46.2 


49 6 • 
43 


48 4 ' 
38 1 


51 9 • 
420 


47 8' 
42.0° 


50 8' 
39.0 


52 6' 
44.0 


47 7 «■ 
400 


49 ■ 
40 7 


57 7 • 
45.9 


50 2 " 
44.0° 


51 2 ' 
40 9 


63 9 " 
45 1 


4a 8 V 
43 2 . 


Area of Residence 


32.6' 
509 


35 8' 
497 


41.5 "' 
453° 


50 
49 5 


533 
52 3 


526 
50 8 


431 
40 6 


52 3 • 
45 1 


485' 
42 2 


41 4 
37 6 


47 8' 
40 7 


45.3° 
41 3 


38 4 
40 2 


42 3' 
45.9 


40 8 
39 7 


41 2 
40 3 


47 3 ' 
43 6 


45 3 "' 
41 6 


41 1 
41.2 


46 9 ' 
44 7 




Rural 
Urban 


4.1 / « 

41' « 


ALL BENEFICIARIES 


50.3 


49 2 


45 1 ° 


49.3 


524 


51.0 


41 


46.3 


43 2 


38 4 


42 3 


42 2 ° 


39.3 


442 


40 3 


40.9 


46 2 


44 2 ° 


41 1 


45 3 


43 4 : 



• Sigri'tlcanHy dderent from the comparison group at the 0.05 level. 
' Significantly dfterent from 1991 to 1993 at itie 0.05 level 

SOURCE: CHER analysis of Medicare Pari B claims and denominator file for a sample of beneficiaries 



mcjnldna\/indirpt\dpp(ix-c\rdMf.w -.V - I.'\iiO 



TABLEC-13 

HEAD CT SCANS BY EXPECTED MFS PAYMENT CHANGE AREAS AND VULNERABLE POPULATION GROUPS, 1991-1993 (age - sex adjusted scans per 1 ,000 beneficiaries) 



O 

















EXPECTED MFS PAYMENT CHANGE AREAS 














ALL AREA 






Reductlof 
1 


^ 


























^ 


Increase 
6 






Vulnerable 
Pooulatlon 


1 ■^— 




2 






3 






4 






6 




W" 


S 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


Shortape Areas 












































All Shortage Conribined 

Urban 

Rural 
Non-Shortage 


72 2- 

73 1 • 
11.2' 
65 


64 6 

65 4 • 
17.9 ■ 
61 7 


63 3«' 

64 1 " 
15.5 ' 
59.3° 


70 8 • 
78 6- 
47 ■ 
638 


68 5 • 
75 4- 
48 ■ 
648 


71.7 • 
77 7 * 
54 5 " 
66 8 


76 3 ■ 
80 8 ■ 
48 9 • 
69 5 


79 9 < 
84 6 • 
51 2 • 
68 5 


81 2" 
87 • 
47 1 ' 
67 2 


68 7 
76 ' 
56 2 • 
67 3 


72.1 
81 4 • 
56 4 • 
67 5 


73 4 " 
81 7 • 
59 3' 
67 3 


683 
91.8 • 
57 5 • 
66 8 


66 8 
90 4" 
56 1 • 
693 


66 4 
94 5" 
53 8 • 

67 9 


672 
669 
67.3 
65 2 


71 1 « 
74 1 " 
69 5 ■ 
64 4 


67 5 " 
70 5 "" 
66 
63 6 


70 6 « 
79 4 ' 
56 6 • 
67 


72 3 " 
82 3 " 
56 5 - 
67 2 


73 ., 
83 7 ^ 
56 3 • 
66 7 


Poor Areas 












































All Poor Combined 

Urban 

Rural 
Non Poor 


97 8 • 
98,9' 
37 6- 
63 2 


90 2* 
912- 
310* 
601 


88 9* 
90 1 " 
20 4- 
57 8° 


77 8' 

78 7 • 
67 6 • 
634 


81 6 • 
81.5 • 
83 1 ■ 
64 1 


78 9 ■ 

78 8 • 

79 1 -^ 
66 4 


79 3 • 
81 9 • 
63 5 • 
68 8 


79 9 • 
82 8 • 
62 7 • 
68 


81 8 ■ 
84 5 • 

65 5 

66 5 


75 1 • 
77 1 • 
63 
66 7 


76 5 • 
78 7 ■ 
63 8 
670 


77 6 • 
79 3 ■ 
68 2 ° 
66 8 


83 7 • 
89.1 • 
75 6 • 
662 


85 9 • 
89.7 ■ 
80 4- 
68 4 


86.2" 
92.1 ■ 
77 9 ■ 
67.0 


68 2 • 
67 8 ' 
68.3 • 
650 


71 9 ■ 
69 4 • 

72 7 ' 
64 1 


70 9 •" 
66 1 • 
72 5 - 
63 2 


77 6 ' 
80 5 " 
67 2 
66 4 


79 • 
61 5 - 
69 9 ' 
66 6 


79 7 ,., 
82 1 . 

710 ,: 

66 


Races 












































Black 
White 


97 • 
653 


89 3- 
62 4 


86 2 " 
59.3 » 


86 4 ■ 
63 7 


89 6 • 
63 5 


91 7 * 
663 


92 1 • 
69 3 


91 6 • 
68 3 


94 3 ' 
65 8 


86 • 
67 2 


88 4 ' 
66 9 


89 9 ' 
666 


97 6 ' 
66 1 


97 7 • 
67 8 


97.9 ■ 
66 2 


74 7 ■ 
655 


76.5 • 
64 


77 7 "t 
62 9 


88 5 " 
66 9 


89 7 • 
66 


91 2 . 
65 7 


Medicaid Elialble 












































Yes 
No 


1145' 
57,8 


108 6' 
54.9 


107 ab 
52 2° 


1130 • 
588 


1182- 
59 1 


1158* 
61 5 


1137 ' 
64 4 


1130 • 
63 7 


1128' 
620 


112 4 ' 
63 3 


1110 ' 
63 8 


1120" 
63 3 


1165 » 
622 


1175 • 
645 


1187 " 
624 


1094" 
584 


108 5 • 
57 6 


108 8 
56 


1132 ' 
62 2 


112 9 - 
62 5 


113 1 , 

01 6 


Disabled 












































Yes 
No 


86 5' 
632 


88 8 • 
594 


81.1 "■ 
57.4° 


85 5- 
619 


86 0* 
62.8 


91 2 " 
645 


94 1 • 
67 1 


91 2 • 
66 7 


92 1 ■ 
652 


89 2 ' 
64 9 


90 2 • 
65 3 


89 • 
65.3 


90.5 • 
64.2 


92 9- 
66.4 


91 3 • 
650 


80 4 • 
63 2 


82 2 " 
623 


81 9 • 
61 2 


89 2 " 
64 7 


89 6 " 
65 1 


89 4 , 
614 


Age 












































85+ Years 
Less than 85 


1235 ■ 
636 


124.8 • 
59.9 


1192 " 
57,5° 


112,4 ■ 
62.9 


112.5 • 
637 


1174 " 
655 


1122 ' 
687 


1152 ' 
678 


1153' 
66 4 


108 1 ' 
66 2 


1126 ■ 
66 4 


1152 •" 
66 1 


102 1 • 
66-0 


110.0 • 
67.9 


108 5 "■ 
66.4 


101 • 
643 


101 2 • 
636 


104 8 " 
62 4 


108 4 ' 
66 1 


1123 " 
66 2 


113 5.,. 
65 b 


Area of Residence 


46 5 ■ 
658 


46 8 ■ 
62.2 


45.6 • 
59 9° 


56.7 ■ 
652 


58.9' 
658 


62 5 • 
677 


62 1 • 
71 4 


61 3 ' 
70 8 


61 5- 
693 


58 6 • 
69 8 


58 9 • 
70 3 


61 1 ■ 
695 


61 8 • 
71 6 


61 6 • 
75 9 


61 ■ 
73 8 


67 f. • 
59 fa 


67 > 
58 9 


64 9 ' 
60 9 


61 9 ' 
69 3 


61 B ' 

09 7 




Rural 
Urban 


62 . 
69 


ALL BENEFICIARIES 


652 


617 


59.4" 


64 1 


64.9 


670 


698 


692 


68 


674 


67 7 


67 7 


66 9 


69 1 


67 8 


653 


64 6 


63 7 


67 2 


6/5 


67 I) 



■ SlgoiViMrtty dmofeni from the companson group at the 05 level. 
» Sianmcanlly diftereni from 1991 to 1993 at the 0.05 level 

source: CHER .ru.l/sJ« of Medicare Part B cl. ms ar«l denornlrulor f,!. to, . «rrpl. of beneflcianes 



moniaiid\fin8lipf^ppnx t vrutjlc 



TABLE C-14 

BRAIN MRI SCANS BY EXPECTED MFS PAYMENT CHANGE AREAS AND VULNERABLE POPULATION GROUPS. 1991-1993 (age - sex adjusted scans per 1 ,000 beneficiaries) 





Vulnerable 
PoDulatlon 














EXPECTED MFS PAYMENT CHANGE AREAS 














ALL are; 






Reductlor 
1 


^ 


























_-^ 


Increase 
6 








■^"^ 




2 






3 






4 






5 




W 


VS 




1991 


199? 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


199_3 




Shortaae Areas 














































All Shortage Combined 

Urban 

Rural 
Non-Shorlage 


18.6' 
18.8- 
7.0 • 
21.7 


20.7' 
20.8' 
13.0' 
26.0 


17.6" 

17.8' 

8.4* 

24.7' 


14.4- 
14.2' 
15.1 • 
19.4 


19.2" 
18.5' 
21.4 
23.3 


20.2* 
20.4" 
19.8" 
24.4' 


14.9' 
15.5- 
11.1 ' 
18.0 


19.2 ' 
19.9 

15.5" 
22 6 


18.1 " 
18.5" 

15.2" 
22.0° 


12.7- 
13.1 
12.1 • 
14.8 


16.2 
17.1 
14.6 
18.6 


16.0" 
17.4° 
13.7 • 
18.6° 


11.1 • 
12.0' 
10.7 • 
13.5 


14.1 ' 
15.4 
13.5' 
16.6 


13.5" 
15.2° 
12.7" 
16.6° 


13.8 
17.5' 
11.8' 
13.4 


18.6' 
24.5' 
15.4 
16.5 


18.6 « 
21.5" 
17.0° 
17.0° 


13.2 ' 
14,2 • 
11,5' 
16.0 


16,9 " 
18.3 ■ 
14,7 - 
19.8 


16.4 „ 
17,9 .K 
140 . 
19,8, 




Poor Areas 














































All Poor Combined 

Urban 

Rural 
Non Poor 


19.4* 
19.5' 
12.9' 
21.7 


18.7' 
18.9' 
5.8' 
26.2 


18.4" 

18.7- 

5.4" 

24.8' 


15.0' 
15.2' 
13.5' 
19.4 


19.6' 
20.0" 
14.8 • 
23.3 


20.7" 
21.1 " 
16.8" 
24.4' 


15.6' 
16.2 
12.0' 
18.1 


19 4' 
19.8" 
17.0' 
22.8 


19.5' 
20.0° 
16.3" 
22.0° 


12.8 

13.0 

0.0 

14.8 


16.7 

16.8 

0.0 

18.6 


17.4° 
17.7° 
15.4" 
18.6° 


12.0' 
13.2 
10.3' 
13.4 


15.1 
14.8' 
15.7 
16.5 


16.0° 
16.8° 
15.0° 
16.4° 


11.8' 
17.6' 
9.9' 
13.6 


14.5' 
21.0' 
12.4 ' 
16.7 


16.0° 
20.7 " 
14.5" 
17.1 ° 


13.9' 
14.7 ' 
11,0' 
15.0 


17.5' 
18.2 ' 
15,0 ' 
198 


18 1 .1 
18,8 L, 
15,3 ,., 
19.7 L. 




Races 












































o 
1 


Black 
White 

Medicaid Ellalble 


17.1 • 
23.1 


18.7- 
27.8 


17.0" 
26.4' 


13.7' 
19.9 


18.2' 
23.7 


20.4" 
24.7' 


14.6' 
18.6 


18.1 ' 
23.3 


19.2" 
22.2' 


12.0' 
15.0 


17.4 
18.7 


17.6° 
18.8 t> 


12.4 
13.5 


15.6 
16.6 


15.6° 
16.4° 


10.0' 
14.1 


12.2' 
17.2 


12,9 '° 
17.7 ° 


12.8' 
164 


16.8 ' 
201 


17.5., 

20 : 




Yes 
No 


20.1 • 
21.8 


21.2 • 
26.5 


24.3' 
24.5' 


20.2 
19.1 


24.1 
23.0 


24.2' 
24.2' 


19.5 

17.7 


23.2 
22.3 


23.5' 
21.5' 


151 
14.6 


16.6 
18.6 


18.8° 
18.4° 


14.1 
13.3 


18.8' 
16.2 


17.9' 
16.2° 


14.7' 
13.3 


16.9 
165 


17.6' 
17.0° 


16 8 
15,7 


198 
196 


20 6 ., 
19 5 „ 




Disabled 














































Yes 
No 


26.8' 
21.1 


28.4- 
25.6 


28.4" 
24.1 ' 


21.7 • 
18.9 


24.9 
22.9 


27.2" 
23.9' 


20.9' 
17.5 


26.4' 
22.0 


26.0" 
21.3' 


17.9' 
14.3 


21.2 
18.2 


20.6° 
18.2° 


16.7 ■ 
12.9 


19.5' 
16.1 


20.0" 
15.9° 


15.7" 
13.2 


17.7 • 
164 


21.1 " 
16.5' 


18.8 ' 
155 


22.4 ■ 
194 


22,7 ., 
19 3, 




85+ Years 
Less than 85 


16.9 • 
21.7 


17.4' 
26.1 


16.8* 
24.4' 


11.8' 
19.4 


16.6' 
23.3 


16.5" 
24.5° 


104' 
18.1 


13.1 ' 
22.7 


13.7" 
22.0' 


d.O- 
14.8 


11.0' 
18.7 


12.1 " 
18.7° 


6.4 • 
13.5 


8.7' 
16.7 


7.7" 
16.6° 


7.7' 
13.6 


8.9' 
16.7 


9,7 °" 
17.3° 


9.0" 
16.0 


11.7 ' 
19.9 


12,1 ., 
19.9, 




Area of Residence 


7.8- 
22.0 


10.0- 
26.4 


10.7" 
25.0' 


17.1 • 
19.5 


20.8' 
23.5 


20.2" 
24.8' 


13.6' 
18.7 


18.4' 
23.3 


18 2" 
22.5' 


12.8 

15.2 


14.1 • 
19.7 


15.6 •° 
19.3° 


11.9' 
14.7 


14.3' 
18.4 


14.5" 
18.0° 


11.6 
18.0 


14.2 • 
22.0 


14.9 " 
22.3 ° 


12.6' 
171 


15.1 ■ 
21 4 






Rural 
Urban 


15 7,,. 
21 1 , 




Al I. BENEFICIARIES 


21.6 


25.8 


24.5' 


19.2 


23.1 


24.2' 


17.9 


22.4 


21.7° 


14.6 


18.5 


18.5° 


13.3 


16.4 


16.3° 


13.5 


16.5 


17.1 ' 


15,8 


19,7 


19 6 : 



• Signincantty different from the comparison group at Itie 05 level 
' Signlflcanllv dtferent from 1991 to 1993 at Itie 0,05 level, 

SOURCE CHER analysis of Medicare P«1 B claims and derwmlnator flk. for a sanple of benenci.nes. 



inonlana\Iinalrpnapf,,,x cVlaUi-i xi-jV IJ,-; 



TABLE C- 15 

ECHOCARDIOGRAMS BY EXPECTED MFS PAYMENT CHANGE AREAS AND VULNERABLE POPULATION GROUPS. 1991-1993 (age ■ sex adjusted tests per 1.000 beneficiaries) 



Vulnerable 
Population 



1991 



EXPECTED MFS PAYMENT CHANGE AREAS 



Reduction 
1 



1992 



1993 



1991 



1992 



1993 



1991 1992 1993 1991 1992 1993 



1991 1992 1993 



""^ Increase 
6 



ALL AREAS 



1991 



1992 J993 



O 



Shortaae Areas 








All Shortage Combined 

Urban 

Rural 
Non-Shortage 


229 3 
2317 
59 0* 
233 9 


260 7- 
262 3- 
156 1 • 
276 3 


3329 

337.4 

62 

3418 


Poor Areas 








All Poor Combined 

Urban 

Rural 
Non Poor 


490 2 • 
497.7 • 
54 4- 
2186 


616 4 • 
626 3 • 
80 9* 
256 5 


943 5 

959 8 

308 

3086 


Races 








Black 
White 


268 4 ■ 
2376 


304 8' 
284 5 


416,0 
349 9 


Medicaid Elidible 








Yes 
No 


391 7 
2103 


467 7 • 
2478 


671 4 
2919 


Disabled 








Yes 
No 


304 0- 

227.4 


356 0' 
2689 


441.0 
3326 



1459 • 


161 1 • 


1902" 


174 6* 


198 4 ' 


236 9 " 


169 2 


194 2 


2476 


158.5 


173.0 ' 


205.2 « 


187.6 • 


212 7- 


255 8 «■ 


189.7 • 


218 3 • 


279 7 


107 5' 


125.7 • 


14b 3 «- 


95 2 ■ 


112.7 • 


125 2 " 


133 9' 


153 3' 


1935 


162 6 


1909 


228 » 


1575 


178.1 


220 3" 


1612 


183,1 


2353 



158.4 • 177,8 210.4 » 
218,3* 244,4* 290 5" 
130 7* 147 4* 174 4 «> 

148.5 169,1 206,7 " 



1409 ' 


166 3 " 


192 " 


156 5 * 


2002 " 


206 4 ^ 


1324 • 


148 " 


184 4 " 


1222 


141,4 


170 7 » 



171 5 * 


184,4 


2121 «■ 


183 6 ■ 


2103 * 


263 9"' 


195 9 • 


223 8* 


289,9 * 


1738 * 


1947 * 


2431 • 


1436 ' 


169 9 " 


200 4 


174 6* 


187 


2140 "^ 


191 6* 


221 1 ' 


279 7 « 


208 3 • 


234 9' 


3044 "^ 


193 7 


2122 * 


265 3 «■ 


1416 • 


182 " 


197 4 


135 2* 


153 1 ■ 


1900*^ 


1348' 


145 9* 


170 9 •» 


122 5 ' 


160 1 * 


207 4 "^ 


1436 ' 


168 9 


2114 » 


1443 


165 9 • 


2014 


161 5 


1901 


227 3 ' 


155 5 


1757 


2166" 


158,6 


1802 


2314 ' 


148 1 


168 6 


205,4° 


121,2 


140,1 


169 2 



180 1 * 


2025* 


228 7° 


1919* 


219 5 • 


273 5 " 


195 7 * 


225 3 * 


2818 " 


1953 


2139 ' 


265,7 *" 


137 3' 


166 1 ■ 


202 2 


162 9 


191,7 


229 4° 


157 6 


177,7 


2195 ° 


161,6 


1829 


244,0 » 


1478 


168 


205 0° 


123,3 


141 5 


169 8 



165 9 " 188 6 ' 230 6 * 

189 9' 216 2' 265 6"' 

127 6' 145 4' 176 3" 

157 8 180 5 224 6" 



192 3 ' 220 7 ' 282 7 " 

207 6 " 237 5 ' 306 6 •" 

136 • 160 2 ° ig/g " 

155 5 177 9 220 5' 



188 0' 214 6° 260 5'" 
158 1 180 5 224 3' 



216 7* 224 6' 292 0*° 
156 1 133 9 219 2° 



213,6 • 


239 3' 


293 "' 


208 7 ' 


240 3 ' 


298 7 *» 


187 7 * 


2124 ' 


255 6" 


1710 ' 


193 9 ' 


233 2 «■ 


212 7 ' 


242 3 ' 


300 5 


1516 


171,7 


2117° 


157 4 


1735 


229 9° 


145 6 


165 5 


2019° 


1154 


134 


160 8 ° 


1523 


174 2 


216 1 



212 2* 


2414 * 


297,9 •° 


204 9 * 


232 4 • 


278 3 " 


2091 ' 


2412' 


298,5 


1567 


1846 


219 1 ° 


153,1 


173,3 


214,6 ° 


156 4 


177 5 


229 



199 2' 224 9' 267 2' 
1433 1633 1998 ' 



59 2' 


182 8' 


2196 " 


204 6 " 


233 8 


2U4 3 


179 


136 8 


164 6° 


152 9 


175 1 


218 1 



85+ Years 
Less than 85 



290 2 * 358 * 436 4 ' 
232.2 273 6 338.5 ' 



186 7 * 212 5 * 252 3 ' 
161.3 139.3 225 9' 



1730' 2004' 274,2' 
1580 178,6 220,4 = 



182,8 ' 


209 4' 


264 *° 


151 1 


178 7 


205 9 ° 


132 9 * 


153 8 " 


176 9 


161 1 


183 


235,1 ° 


149,2 


169,4 


207 0° 


1226 


141,9 


1712 



175 2' 203 2" 247 8' 
157 8 180 3 224 2' 



Area of Residence 



Rural 
Urban 

ALL BENEFICIARIES 


1121 * 
2377 

233.8 


1153* 
2313 

2759 


129,3 *° 
348,9° 

341,6° 


157 6 
152,6 

162,0 


1966 
1838 

189 9 


253 4 "° 
222,6 ° 

226 6° 


121 1 * 
•65,9 

158,5 


138 5 ' 
187,4 

179,2 


161,9" 
2332 ° 

221,3 ° 


136 6 • 
1637 

161,7 


158 6' 
1908 

183 7 


1941 " 
247,9 ° 

236 0° 


131 3 ' 
1654 

149 2 


146 7 * 
190 3 

169,7 


183 7 «■ 
227 7 ° 

207,0 » 


125 6' 
116,3 

122 9 


144 4 ' 
136 9 

142 2 


175 1 " 
162 ( ° 

171 4 - 


131 4 • 
168 6 

158 2 


150 9 ' 
192 6 

1B1 


18t. 1 "" 
240 3 

2.>A 9 '■ 



■ SlanillMnlly diller.nl from Ih. comparison group >t th. 05 lovrt, 
' Slgnfflcntly dl(I.r.nl from 1081 lo 1093 >l Ih. 0,05 l.v.1. 



SOURCE: CHER analyuft 



of Medlc«r« P«rt B claim, and d«wmlnator 111. tot a sampl. of b.n«flclan.s. 



m jntana\fiiirflf plLip^tu c\ I ^Mf 



TABLEC-16 

CARDIAC CATHETERIZATIONS BY EXPECTED MFS PAYMENT CHANGE AREAS AND VULNERABLE POPULATION GROUPS, 1991-1993 (age - sex adjusted procedures per 1,000 beneficiaries) 



Vulnerable 
Population 



EXPECTED MFS PAYMENT CHANGE AREAS 



Reduction 



1991 1992 1993 



1991 1992 



1993 



1991 1992 



1993 



1991 1992 1993 



1991 1992 1993 



Increase 
6 



1991 1992 



1993 



ALL AREAS 



1991 1992 1993 



Shortage Areas 

All Shortage Combined 22 5 212* 186' 

Urban 22 7 212' 18 8' 

Rural 96- 213 57' 

Non-Shortage 23 6 23 4 23 9 



20 9* 22.3* 22 8'» 19 1* 20.2* 20.3 • 19,4 22 9 22 1' 16,6 • 20 0* 20 6' 

214' 21-7* 219" 18 8' 20,1* 20,3' 18 5' 214 19 5* 19,1 20 2' 216 

19 5' 24,0' 25,3" 20 9' 20 9' 19,9' 211 25 4 26 3" 18 3' 19,9" 20 1' 

24 3 29 28 6' 23,6 25 1 24,7 212 23 8 23 1 21,2 23 4 23,6' 



189 • 


21 • 


23 1 ' 


193 ' 


21 4 ' 


21 3 


17,0 ' 


20 3 ' 


20 1 " 


190 • 


20 8 • 


20 3 


20 0' 


21 3 ' 


24 7 ' 


19 7 ' 


22 3' 


23 


21,3 


22 9 


23 0' 


22 2 


24 5 


24 2 



Poor Areas 

All Poor Combined 

Urban 

Rural 
Non Poor 



17 8 • 19,4 ' 

18 ' 19,5 ' 
9,3' 11,9' 

23 9 23 5 



19 4 ' 
19,5 ' 
139 ' 
24 



19,4 ' 19 8 ' 

192' 195' 

22 2 ' 23 ' 

24 4 29 2 



21 ' 
20 3 ' 
29 2 ' 
28,7 I 



18 8* 20 9' 

18 1 ' 20 6 ' 

22 8 22 9 ' 

23 9 25 3 



20 1 ' 
19 5 ' 
24 
24 9 



15 2' 17 3' 

143 • 163 ' 

20,6 23 5 

21,6 243 



173 ' 
159 ' 
25 8 ' 
23 5 



18 6 ' 
152 ' 
23 6 ' 
21 1 



20 9 ■ 21 5 " 

17,5 ' 17 3 " 

25 8 ' 27 6 " 

23 3 23 4 ' 



17,6 ' 19,7 ' 

14 6' 16 0' 

18 6' 20 9' 

215 23 1 



19 3 " 
155 • 

20 6 " 
23 2 » 



173 ' 
16 3 ' 

21 ' 

22 4 



193 ' 
18,3 ' 

23 ' 

24 8 



192 ' 
177 ' 
24 2 ' 
24 4 ' 



O 
I 



Races 



Black 
White 



16.7' 16 P" 15 7' 
249 24.5 248 



16 1 ' 


17 7 • 


18 5 " 


17 5'' 


19,2 ' 


18 8 ' 


15,3' 


166 ' 


169 • 


15,3 • 


17 1 • 


18 2" 


10 2' 


13 0' 


1? 1 " 


15 4 • 


17 1 ' 


17 3 


250 


30.2 


29,5'' 


245 


25 7 


25 4 


21 9 


24 7 


238 


21 8 


23,8 


23.8 


22,9 


24 2 


24 2 


23 


25 3 


24 :l 



Medicaid Eligible 

Yes 

No 



22,0 • 20 6 ' 20 ' 
23,8 23,7 244 



246 


26,5' 


27 8 ° 


22 4 


238 


23 6 


17,5' 


21 


20.8 ' 


19.0 ■ 


19 3 ' 


20.7 ' 


17 9 • 


21.2 • 


19 • 


20 1 ' 


22 1 ' 


-'9 


241 


290 


28 4 ' 


23 5 


25,0 


24 6 


21.4 


24 


233 


21.2 


23 5 


23 6 ' 


21 7 


23 1 


23 6 ' 


22 3 


24 6 


2-13 



Disabled 



Yes 
No 



38.8 • 37 7 ' 36 7 ' 
22,2 22 1 22 6 



37 7 ■ 


41.3 ' 


41.7 " 


33 4' 


36 2' 


33 6 • 


26 9- 


33 4 ' 


31 9 " 


31 2 ' 


34 1 • 


33 2 • 


29.1 • 


33 2 ' 


30 6 • 


31 U ' 


35 1 ■ 


33 6 


227 


27 5 


27.0 ' 


22 2 


23 6 


234 


20 4 


228 


22 


198 


21 9 


22 2 


20 1 


21 5 


21 9 ' 


21 


23 2 


23 



85+ Years 
Less than 85 



50 ' 


5.0 ' 


48' 


3 7 • 


48' 


4 4 " 


3.6 ■ 


48 • 


4 2 • 


2.8' 


37 • 


40 " 


23 ' 


30 • 


33" 


2 3 • 


28' 


33 " 


3 • 


3 9" 




14.1 


23.8 


244 


24.7 


294 


291 ' 


23.9 


25.4 


251 


21 6 


24 4 


23 7 


21 5 


23 8 


24 ' 


21.7 


234 


23 6' 


22 6 


25 


24 7 



Area of Residence 

Rural 

Urban 



14.8 ' 
239 



13.9' 
236 



16-0' 
24 1 



ALL BENEFICIARIES 23 6 23 3 23 8 



26.3 ' 
238 



30.4 
285 



241 287 



30 7 " 

28.0 ' 

28 4 ' 



24 1 
232 



23.3 



26.8 
24.4 



24.8 



25.5 
242 



24.4 



20 8 

21 1 



21.1 



242 
23.7 



238 



24 ' 
228 



23 



19 4' 22 5 
22 4 23 8 

21 23.2 



23 2 ' 
235 



23.4 ' 



21.6 23.2 
203 22.0 



21.2 22 9 



23 3 ' 
22.1 ' 



23 ' 



21 3 24 1 

22 3 24 5 



22 24 4 



24 1 ' 

24 ' 



24 1 



' SIgnltlcantly ditterent from the comparison group «t the 0.05 level. 
- Significantly dltterenl from 1991 lo 1993 at the 05 level, 

SOURCE CHER analysis of Medicare Part B claims and denominator file for a sample of benef.cianes 



[nontanatflnalfpt\aiipnx cMdDlc^ ti\j u, 



TABLEC-17 

UPPER Gl ENDOSCOPIES BY EXPECTED MPS PAYMENT CHANGE AREAS AND VULNERABLE POPULATION GROUPS, 1991-1993 (age - sex adjusted procedures per 1 ,000 beneficiaries) 





Vulnerable 














EXPECTED IVIFS PAYMENT CHANGE AREAS 






















Reductio 


^ 


























-^ 


Increase 








1 ^^ 






























Population 




1 






2 






3 






4 






5 






6 






ALL AREAS 




1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 




Shortaae Areas 














































All Shortage Combined 
Urban 


41.2 


39.4 


39.3" 


39.8 


41.7 


42.1 ' 


40.5 


39.3 


41.8 


35.2 


35.7 


39.1 " 


31.5 


34.3 


36.0° 


37.6' 


39.0' 


40,9 ■' 


36.2 


36,9 


23.4 t, 




41.4 


39.7 


39.7 


42.0- 


44.1 • 


44.2 ■ 


42.1 • 


40.4 


43.5 


38.5 


37.8 


41.1 


36.8 • 


40 0* 


41.6'° 


38.6' 


43.1 • 


46.5 '° 


39.9* 


39,8 ' 


42,4 ,:, 






27.6" 


19.2' 


15.6- 


33.0' 


34.6' 


36.2"° 


31.1 • 


33.3" 


31.6* 


29.5' 


32.0' 


35.7° 


29.1 ■ 


31.7' 


33.5° 


37.0" 


36.9 


380 


30.3' 


32,5 •• 


34.7 ., 




Non-Shortage 


42.3 


40.9 


42.5 


37.6 


39.4 


40.4 


37.8 


38.2 


39.9 


34.9 


36.1 


38.2 


33.7 


34.8 


35.4 


35.3 


37.0 


38,7 ' 


36.0 


37.0 


38.6 1 




Poor Areas 
















































50.4' 


51.3' 


51.1 • 


40.0' 


44.5' 


42.4 ' 


40.6 


41.8" 


42 6 


35.3 


38,6 


41.7° 


36.4 ' 


39.2- 


39.8* 


36.9 


37.6 


410"° 


38.1 


40,4 • 


42,1 <, 






50.8' 


51.7' 


51.6* 


40.0 


44.8' 


42.5° 


41.6 • 


42.4" 


43.0 


35.3 


38 4 


42.1 " 


36.4" 


36.9 


38.1 ■ 


34.9 


374 


39,0° 


38.5 


40.7 • 


42 4 ,„ 




Rural 


25.7' 


28.4 


28.7* 


39.5 


41.1 


40.7 


35.1 


38.0 


40.4° 


35.2 


39.5 


39.7° 


36.5 ■ 


42.5' 


42,3 * 


37.5 • 


377 


41,6 " 


36 2 


39,2 - 


41 ^ 




Non Poor 


41.8 


40.2 


41.9 


37.6 


39.2 


40.4 


37.7 


37.9 


39.7 


34.9 


35.8 


38.0 


33.4 


34.6 


35,2 


35,3 


37,1 


38.6 '■ 


359 


36,7 


38 3,, 




Races 














































Black 


44.8 


44.8 • 


47.5 «■ 


43.6' 


46.7' 


48 2 ^ 


45.2 " 


46.7" 


46 2 • 


38.1 


40.5" 


41.6° 


41.0' 


42.7" 


45.0 " 


35.4 


39.3 ■ 


40,2 ' 


40.8 


43,1 ' 


44.0 ,.i 


o 
1 


While 


43.4 


41 9 


43.3 


38.0 


39" 


40.5 


37.9 


37.8 


39.2 


35.4 


362 


38.3 


33.5 


34.4 


35.0 


36.1 


37,1 


38 9 t) 


363 


369 


38 4 


^ 


Medicaid Eliaible 














































Yes 
No 


61.7' 


62.9' 


65.5"' 


65.5 • 


64.8' 


68.6' 


61.0" 


66.2 • 


66.1 "° 


50 4" 


52.4' 


55 1 • 


54.0 • 


54.4' 


57.4 ■ 


52,0 ' 


56,3- 


57,3 " 


56 2 


58.7 ' 


60 6 ., 




39.4 


37.6 


38.9 


34.7 


367 


37.3 


35.1 


34.7 


36.5 


33.5 


345 


36.6 


31.6 


32.9 


33.1 


32.8 


34.0 


35,6 ' 


33.8 


34 6 


36 0. 




Disabled 














































Yes 
No 


58.2' 


58.2' 


57.2* 


54.1 • 


56.2 • 


56.8" 


52.8" 


55.5' 


55.4" 


46.5" 


46.5" 


49,7 ■ 


45.7 • 


51.4 • 


49.8"° 


45.9" 


49.8 ' 


52,8 ' 


489 


51 3 ' 


52.3 . 




40.8 


39.3 


41.1 


36.0 


37.8 


38.7 


36.3 


36.3 


38.2 


33.6 


34.9 


370 


32.1 


32.9 


33.7 


33.9 


35,4 


36,8 ' 


346 


35,4 


37,0 . 




Bsa 














































85+ Years 
Less than 85 


53.5' 


53.0' 


58.3" 


49.5' 


49.6' 


51.5" 


46.9' 


46.8' 


46.6* 


40.6' 


43.0' 


44.6" 


36.6' 


38.4' 


37.2 


39 7 " 


41.7 • 


43,5 " 


42.7 


44,0 ■ 


44,9 * 




42.0 


40.5 


41.9 


37.4 


39.2 


40.1 


37.7 


38.0 


39.8 


34.8 


35.8 


38.1 


33.5 


34.7 


35.4 


353 


37.0 


38,6° 


35.8 


36,8 


38,4 ,. 




Area of Residence 














































Rural 
Urban 


23.5" 


24.1 • 


23.5" 


33.6' 


34.1 • 


38 0° 


36 


40.2 


40.7° 


313" 


33.4 


33.0" 


32.1 


33.7 


33 6 • 


35.8 


37,1 


38 8 ' 


33.3 


35 2 ■' 


35 7 ,: 




42.9 


41.4 


43.1 


38.4 


40.3 


40.8 


38.4 


37.9 


39.9 


35.9 


36.8 


39.8 


34.9 


35.7 


37,1 


34.3 


37.0 


38,6° 


371 


37 7 


39 7 




ALL BENEFICIARIES 


42.3 


40.8 


42.4 


37.7 


39.5 


40.5 b 


38.0 


38.3 


40.0 


34.9 


36.0 


383 


33.5 


34.8 


35.4 


35.4 


37.1 


38,7 ° 


36,0 


37.0 


38 6 , 



NOTES: „ „. , , 

• SlgniflcanDy different from Ifie comparison group at the 05 level 

• SlgrtflcanHy different from 1991 to 1993 at me 0,05 level 

SOURCE CHER anatysis of Medicare Part B claims and denominator tile lor a sample of beneficianes 



riryn!ana\finairpi\appnx-<:^Tarjit;'j «ihii . U^i) 



TABLEC-18 

SIGMOIDOSCOPIES BY EXPECTED MFS PAYMENT CHANGE AREAS AND VULNERABLE POPULATION GROUPS, 1 991 -1 993 (age - sex adjusted pro:;edures per 1 ,000 beneficiaries) 





Vulnerable 
PoDulatlon 














EXPECTED MFS PAYMENT CHANGE AREAS 














ALL AREA 






Reductlor 

1 


























^ 




Increase 
6 








1 ^ 




2 






3 






4 






S 


W 


S 




1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 




Shortaae Areas 














































All Shortage Combined 

Urban 

Rural 
Non-Shortage 


37 4* 
37 3 • 
44 3 • 
591 


32 2- 
31 9 ■ 
52 4 
518 


23 1 - 
23 1 " 
23 8" 
43,7 " 


35,7' 
37 8 • 
29 3* 
539 


30 7 • 
30 8 • 
30 4- 
477 


27 6 " 
28,6 " 
24,5 ■" 
43 5° 


27 8 • 
26 8 ■ 
33 9 • 
43 2 


25 0* 
23,9" 
31 6 • 
399 


22 6 " 
22,0 * 
26,2 " 
35 7 - 


32 2' 
31 8 • 

33 0- 
463 


30,3 • 

29 9' 

30 9' 
41,2 


25 3 " 
24 8" 
26,2" 
38 8° 


37.6 • 

35.7 ' 
38 4 ' 
452 


35 8- 
33 4' 

36 8 ■ 
41 5 


30 "° 
29,6 " 

30.1 " 

37.2 ° 


28 3 ■ 
33 7 ■ 
25,3 - 
31 


23 9- 
29 7 
20 8 ' 
29 9 


21 3 * 

25 2 ° 
19 3 •° 

26 3 ° 


32 6 " 
31 3 • 
34 5 " 
45 4 


30 » 
28 4 ' 
32 5 ' 
41 2 


25 7 ., 
24 7 ^ 
27 1 I 
37,5 . 




Poor Areas 














































All Poor Combined 

Urban 

Rural 
Non Poor 


30 1 • 
30 2 • 
24 2- 
60 2 


27,0 • 
27,0 • 
27 9 • 
526 


20 9 ' 
20 9* 
22 7' 
44 4" 


33 • 
33 2 ■ 
29 7 • 
543 


29 2' 
29 3 • 
27 8- 
480 


29 2" 
29 4 " 
26 6" 
43 6 " 


27 6' 
27 9- 
25 2- 
44 


24 8- 
25,5 ' 
21 • 
40,7 


21 8 " 

22 4 " 
186 " 
36 4° 


31 7 ' 
32,4' 
275 
467 


28 1 ' 
28 9' 
232 
41.7 


25 1 " 
25,9 " 
20 6" 
39 2 ° 


32 2 " 
33,7 ' 
29.9 • 
45 2 


29 6' 
31 1 ' 
27.4" 
41,6 


26 4 " 
27,6 " 
24 8 " 
37,2 ° 


25 1 ■ 
25 1 • 
25 1 ■ 
31 4 


23 5" 

22 7 " 

23 7 < 
30 2 


21 2 " 

22 8 « 
20 7 ■"' 
26 5 ° 


29 9' 

30 7 - 
26 8 • 
45 9 


26 8 ■ 

27 7 " 
23 6 " 
41 6 


24 t. 
24,8 I 
21 2l 
37 8 I 




paces 












































o 


Black 
White 

Medicaid Elialble 


26 3' 
61 3 


22 3' 
53 8 


17,4- 
45 9 " 


30 6 ■ 
56 


28 1 ' 
49 3 


27 3 " 
45,1 ° 


25 9 • 
44,7 


23 6 ' 
41 2 


21 3 " 
37,0° 


29 6 • 
47 7 


27 1 • 
424 


23 2 " 
39 6 ° 


30 1 • 
46 7 


29 • 
42,8 


25,3" 
38,0 ° 


20 2" 
327 


17 6" 
31 5 


17 3 - 
27 5 ° 


27 7 » 
47 


25 5 ■■ 
42 5 


38 6 c 




Yes 
No 


24 3 • 
636 


21 8- 
55 6 


18,9" 
46 8 » 


27 6 • 
56 1 


25 8 • 
494 


21 6 " 
45 4° 


26 1 ' 
44 3 


23,5' 
41 


199 " 
37,0 ° 


26 5 ' 
47,2 


24 2' 
42 1 


21 4 " 
39 7 » 


28 2 • 
46 2 


23 6 ■ 
42 8 


21 6 " 
38,3 " 


23 0" 
322 


20 3 • 
31 2 


18 4 •" 
27 5 ■• 


26 3 ■ 
46 7 


23 6 • 
42 4 


20 G 
38 7 . 




Disabled 














































Yes 
No 


42 1 • 
60 


36 4- 
52,6 


30 4 " 
44 3 " 


38 1 • 
54 9 


31 8 • 
48 6 


30 4 " 
44,3 " 


29 9 • 
43 7 


27,8 ■ 
40,3 


24 8 " 
36 2 ° 


33 1 ' 
46 8 


29,5 • 
41 8 


28 8 ■' 
39 1 ° 


32 4 • 
46 1 


31 0' 
42 3 


27,7 ■° 
37 8 ° 


24,0 ' 
31 9 


2? 6 • 
30 7 


18 9 '° 
27 2' 


32 1 " 
46 2 


29 1 ■■ 
41 8 


2i"> 8 . 
38 , 




Am 














































85+ Years 
Less than 85 


34 8 • 
59,2 


34 6" 

51,7 


58 3 " 
41,9" 


31,2 ' 
538 


28 6" 
476 


25 0" 
43,5° 


25 8' 
428 


22 9 ' 
396 


21 4" 
35 4° 


29,0' 
459 


26 8 • 
41 


21 7 " 
38 6 ° 


25 9 • 
45 2 


23 4" 
41 6 


20 7 " 
37,3° 


20 7 ' 
31 2 


20 4 ■ 
30 


17 6 "° 
26 4 ' 


27 4" 

45 2 


25 2 ' 

41 


21 H :. 

3/ 3 , 




Area of Residence 














































Rural 
Urban 


53 4* 
58 7 


42 6' 
51 6 


36,5" 
43.4' 


42,1 • 
55,0 


36,7' 
48,7 


33 4 " 
AAA" 


31 5 • 
44 5 


28 2 • 
41 3 


24 " 
37 2° 


39 5' 
47 1 


33 8' 
42 5 


31 " 
40 " 


41 4° 
47 6 


37 6" 
44,3 


33,5 " 
39,7 ° 


28 ' 
380 


27 8 " 
34 2 


24 4 "" 
30 4 " 


36 7 -• 
47 9 


33 1 ■■ 
43 4 


29 5 1 
39 7 L 




ALL BENEFICIARIES 


586 


51 3 


43,2 " 


533 


47,1 


43 ° 


42 3 


39 1 


35,0° 


45 4 


40 6 


38 ° 


44 7 


41 1 


36,7 ° 


30 9 


297 


26 1 '■ 


44 7 


40 6 


36 a :. 



■ Signl'flcanlly diHerenl from the companson ^oup at Dw 05 level 
» Signiricantly aitferent from 1991 to 1993 at me 05 level 

SOURCE: CHER ana^s ol Medicare Part B claims «A denomlnalor flie tor a sample of ber^ficarles 



montand'\liaiilrpt\dfjf^ru t 



TABLE C-19 

COLONOSCOPIES BY EXPECTED MFS PAYMENT CHANGE AREAS AND VULNERABLE POPULATION GROUPS, 1991-1993 (age - sex adjusted procedures per 1 ,000 beneficiaries) 





Vulnerable 
Population 














EXPECTED MFS . AYMENT CHANGE AREAS 














ALL are; 






Reductloi 
1 


■^- 


























k. 


Increase 
6 








n ^^ 




2 






3 






4 






5 




W 


\S 




1991 


.199? 


1993 


1991 


199? 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 




Shottaqe Areas 














































All Shorlage Combined 

Urban 

Rural 
Non-Shortage 


41.2' 
41.2' 
40.9* 
51.8 


41.0' 
41.1 ■ 
34.4' 
54.6 


45.8'' 
46.1 " 
23.7" 
54.0 


32.5" 
33.1 • 
30.7' 
43.5 


36.7' 
37.1 • 
35.5- 
47.1 


35.2 " 
35.4" 
34.6" 
49.1 ° 


33.4' 
34.1 • 
29.6 ■ 
40.7 


35.1 • 
35.9 • 
30.6' 
42.2 


35.7* 
36.7' 
29.8" 
42.8 


33.9 • 
35.7 
30.8" 
38.0 


37.4" 
393 
34 3" 
42.2 


37.7 " 
38.5" 
36.4 " 
43.8° 


32.1 " 
34.4 
31.1 • 
36.0 


35.5 " 
39.3 
33.8" 
38.4 


38.1 ° 
44.9" 
35.0" 
38.7° 


34.8' 
37.5" 
33.4 
33.4 


38.3 
43.8" 
35.4 " 
37.7 


40.9 "° 
46.2 " 
38,1 ' 
38.9' 


33.5" 
35.0" 
31,0 • 
39.1 


36,5" 
38,1 • 
33 9 " 
42.2 


37,5 * 
38 9 =. 
35,3 * 
43.3.. 




Poor Areas 














































All Poor Combined 

Urban 

Rural 
Non Poor 


44.5' 
45.0' 
15.9' 
52.0 


42.7' 
43.2 • 
14.4 • 
54.9 


44.1 ' 
44.3- 
30.0- 
54.3 


32.4' 
32.2- 
34.6' 
43.7 


36.0" 
35.9' 
37.3' 
47.2 


36.7" 
36 7" 
36.3 ■ 
49.2° 


34.5' 
35.4' 
29.3" 
41.0 


37.4" 
38.2' 
33.0' 
42.3 


37.1 " 
37.9* 
32.3" 
43.0 


36.2 
36.7 
33.3 
37.9 


38.7" 
39.0 
37.1 
42 2 


39.6" 
40.0 
37.6" 
43.8° 


34.3 
34.0 
34.8 
35.8 


37.2 
35.7" 
39.5 
38.2 


40.4° 
39.0° 
42.4 " 
38.6° 


29.4 " 
29.1 " 
29.5" 
33.8 


32.6' 
32.9" 
32.5' 
38.1 


34 7 « 
33.7 "° 
35.0 '■ 
39 3° 


34.9 " 
35 8 ' 
31 6 • 
391 


37.5 ' 
38 1 • 
35,2 • 
42,2 


38,4 -■■ 
38 9 » 
36,6 * 
43 3: 




Races 












































1 


Black 
Wtiite 


35.6' 
54.3 


36.6- 
57.1 


36.4' 
56.8 


35.2 • 
44.5 


36.9' 
479 


39.2" 
50.3° 


38.4 
41.2 


37.6' 
42.9 


38.5" 
436 


32.5" 
387 


35.9 • 
43.0 


36.9" 
44.5 t 


32.3 • 
368 


37.1 
38.5 


38.4° 
39.1 


27.9' 
347 


32.2 • 
38.8 


34.1 « 
39 9' 


33,8 ' 
39.9 


36,3 " 
42 9 


37 5 • 
44.1 ^ 


D 


Medicaid Ellalble 














































Yes 
No 


38.3' 
53.5 


40.5- 
56.2 


41.5" 
55.6 


38.0' 
43.7 


39.3" 
47.5 


41.4 " 
49.5° 


36.9' 
40.7 


38.7 ■ 
42.2 


39.9 
42.7 


32.7 • 
38.2 


36 0" 
42.4 


36.9 "' 
44.1 ° 


30 6" 
362 


33.1 • 
387 


34.6" 

39.1 ° 


30.5" 
33.9 


34 4 ' 
38,2 


35.3 
39.6' 


34,1 ' 
393 


36 6" 
42,5 


37.8 .- 
43,6 




Disabled 














































Yas 
No 


47.4' 
51.9 


50.8' 
54.5 


51.5" 
54.0 


42.5 
43,2 


46,2 
46.7 


46.7° 
48.8° 


38.3 
40.5 


41.0 
41.9 


40.4 
42.6 


36.8 
37.8 


39.4 
422 


39.3" 
44.0° 


33 2 • 
36.1 


38.7 
38,1 


38.0° 
38.8° 


31.4" 
33.7 


35.6" 
38.0 


38 5 ' 
39.1 ' 


36 a • 

390 


40 3 ' 
42 1 


40,4 -. 
43,3. 




Aac 














































85+ Years 
Less tt)an 85 


36.0' 
52.0 


40.4' 
54.6 


41.9" 
54.2 


28.6' 
43.5 


32.9' 
47.1 


33.4" 
49.1 ° 


26.8' 
40.7 


29.0" 
42.2 


29.5" 
42.8 


26.5" 
38.0 


28.4 • 
423 


77. T 
44.0° 


22.5" 
36.1 


23.8" 
38.6 


25.3" 
39.1 ° 


24.6 " 
33.7 


27.2" 
38.0 


26.1 "> 
39.4 ■- 


26,3 ' 
39.1 


28.5' 
42.3 


28 7 « 
43 4 ■ 




Area of Residence 














































Rural 
Urban 


26.9" 
52.4 


28.0' 
55.1 


28.0' 
54.7° 


41.3 
43.4 


45.8 
46.8 


50.4° 
48.4° 


34.2' 
41.5 


37.5- 
42.7 


38.3"° 
43.2 


34.4" 
38.7 


37.9" 
43.0 


37.8"° 
45.1 ° 


32.4 " 
38.8 


35.4" 
40.7 


34.6" 
42.4° 


32.6 • 
35.6 


36.9" 
39.5 


38,7 ' 
39.6 • 


33 7 - 
40,7 


37 2 ' 
43 7 


37 7 
45 




ALL BENEFICIARIES 


51.6 


54.2 


53.8° 


43.1 


46.7 


48.6° 


40.3 


41.8 


42.4 


37.7 


41.9 


43.5 ° 


358 


38.2 


38.7 ° 


33.4 


37.7 


39.0 ° 


38.7 


41 9 


43.0 , 



NOTES: 

■ SIgrttlcontly diflerent from (he companson group ot the 05 level 
' Signlflcantty afferent from 1991 to 1993 at the 0,06 level. 

SOURCE: CHER analysis of Me<llcare Pari B claims and denomlnatof file for a sample of beneficiaries 



mo(iidna\finaifpi\iip[>[ix-(,\ldtilt-i .xb\i_ ij«i.1 



TABLE C-20 

CORONARY ARTERY BYPASS GRAFT SURGERIES BY EXPECTED MFS PAYMENT CHANGE AREAS AND VULNERABLE POPULATION GROUPS, 1991-1993 (age - sex adjusted procedures per 1 ,000 beneficiaries) 



Vulnerable 
Population 



Shortage Areas 

All Shortage Combine 

Urban 

Rural 
Non-Shortage 

Poor Areas 

All Poor Connbined 

Urban 

Rural 
Non Poor 

Races 

Black 
White 

Medicaid Eligible 

Yes 
No 

Disabled 

Yes 

No 

Age 



EXPECTED MFS PAYMENT CHANGE AREAS 



Reduction 



1991 1992 1993 



3.9 • 3.6 • 3.3 ' 

4.0 • 3.5 • 3.3 ' 

0.0 • 8.6 2.1 

4.7 4.4 4.7 



3.5 • 3.4 • 3 1 •" 

3.6 ■ 3.5 • 3.2 "^ 
1.3' 1.0* 1.7 ■ 

4.7 4.4 4.7 



1991 1992 1993 



1991 1992 1993 



Inci jase 
6 



ALL AREAS 



1991 1992 1993 1991 1992 1993 1991 19^ 1993 1991 1992 J993 



3.5' 


4.1 • 


4.2 •" 


4.1 ■ 


4.1 • 


3.7' 


4.3 


4.5 


4.1 


46 


4.7 


4.6 


4.2 


4.7 


4.8 " 


4 3 ■ 


4 4 * 


4 2 


3.4 ■ 


3.9' 


4.0 -^ 


4.0 ■ 


3.9 ■ 


3.5 • 


4.0 


4.4 


3.2 • 


3.9 • 


4.1 • 


4.1 • 


3.1 • 


4.0' 


3.9 «■ 


3 9 • 


4 1 • 


3 5 


3.8 • 


4.5' 


SO" 


4.7 


5.1 


4.5 


4.9 


4.6 


5.6 


49 


5.0 


4.9 


4.8 


5.1 


5.3 


4 8 


4 9 


5 2 


b.O 


5.6 


5.1 


5.2 


5.5 


5.2 


4.7 


5.2 


5,1 


4.9 


5.1 


5.0 


46 


4.8 


5.0 


4.9 


52 


51 



3.4' 


3.0' 


3.3' 


4.0 • 


3.8' 


3.6 


3.3* 


2.9* 


3.0' 


3.8' 


3.6' 


33 


4.3 


4.4- 


7.2 •» 


5.2 


4.7 


4.8 


5.0 


5.7 


5.1 


5.3 


5.6 


5.3 



3.0 • 3.2 • 3.2 • 3.7 ■ 3.8 ' 

2.9 • 3 1 • 2.7 • 2.9 ■ 3.0' 

3.8 • 3.7 • 6 " 5.1 4.8 

4.8 5.3 52 4.9 5.1 



3.8' 
2.8' 
5.1 
5.0 



3.7' 
3.2 ' 
3.8' 
4.6 



4.2 • 
3.7 ■ 
43 
4.9 



4.7 ^ 
6.1 •» 
4.2' 
5.0 



1.9- 


2.0' 


1.5* 


1.9' 


2.1 • 


2.2 * 


2.6' 


2.9' 


2.6" 


1.8' 


2.1 • 


2.6 «■ 


2.1 • 


2.2 • 


2.3" 


1.6* 


1.7 • 


1 5 


5.0 


4.S 


5.0 


5.2 


5.8 


5.3 


5.5 


5.8 


5.4 


50 


5.5 


5.3 


51 


5.2 


5.1 


4.9 


5.2 


54 



3.3' 


3.6' 


3.4 ■ 


3.3' 


3.5" 


36- 


3.8 • 


3.9' 


4.0 • 


3.1 ■ 


3.2 • 


3.1 • 


2.8' 


3 1 • 


3.4' 


3.1 • 


3 2 • 


3 2 


4.8 


4.5 


4.8 


5.1 


5.8 


5.2 


5.3 


5.6 


5.3 


4.8 


5.3 


5.2 


5.1 


5.2 


51 


4.8 


5.1 


5.3 



7.9- 


6.5' 


6.6 -> 


6.3' 


7.0- 


6.7' 


6.2 • 


6.6" 


5.9 


6.4 • 


6.4' 


5.7 


6.5* 


6.2' 


6.0- 


6.2 ■ 


6.5'' 


6 1 


4.4 


4.2 


4.5 


4.8 


5.4 


A.9 


5.0 


5.3 


5.0 


4.5 


5.0 


4.9 


4.7 


4.9 


4.8 


4.3 


4.6 


4.8 



3,5 ■ 
3.3' 
4 4 • 
5.0 



2.0 ' 
5.2 



3.3' 
5.0 



6.4 ' 
4.7 



3,5 ' 
3.3 ' 
4.3 ' 
5.3 



2 3 ' 
5,5 



3 4 ' 
54 



6,5 ' 
5.0 



NOTES: 

• Significantly different fronn the comparison group at tfie 0,05 level. 
» Significantly different from 1991 to 1993 at ttie 0,05 level 

SOURCE, CHER analysis of Medicare Part A clainns and denominator file for a sample of beneficiaries 



3.5 ■ 
3.1 • 
5.0 » 
51 



2,4 •" 
5 3 



3,5 ' 
52 



6 •" 
4,9 



85+ Years 
Less than 85 


0.6* 
4.8 


0.6' 
4.5 


0.8' 
4.8 


0.4- 
5.0 


0.6- 
5.7 


1.0 " 
5.2 


0.5 • 
5.3 


0.5 • 
5.6 


0.7 * 
5.3 


0.3 • 
4.8 


0.5 " 
5.3 


0.6 • 
52 


0.3" 
5.0 


0.4 • 
5.2 


0.3* 
5.1 


0.2' 
4.7 


0.4" 
4.9 


0.4 •" 
5.1 


0,4 '■ 
5,0 


0,5" 
5,3 


0,6 -» 
5,2 


Area of Residence 












































Rural 
Urban 


3.2- 
4.7 


3.9 
4.4 


3.4 ■ 
4.7 


5.2 
4.9 


5.3 
5.6 


5.7 
5.0 


5.4 

5.1 


5.8 
5.4 


5.1 
5.1 


4.6 
4.7 


5.1 
5.2 


5.4 
4.9 


4.8 
5.0 


5.0 
5.1 


4.8 
5.0 


4.6 
4.4 


4.8 

4.8 


5.1 

4.7 


4.8 
4.9 


5.1 
5,2 


5 1 
5,0 


ALL BENEFICIARIES 


4.6 


4.4 


4.7 


4.9 


5.5 


5.1 


5.1 


5.4 


5.1 


4.7 


5.2 


5.0 


4.9 


5.1 


4.9 


4.6 


48 


50 


4,8 


5,2 


50 



montana\finalfpn3pp(ix c\l.jhl<--^. *l . 



TABLE C-21 

PTCAs BY EXPECTED MFS PAYMENT CHANGE AREAS AND VULNERABLE POPULATION GROUPS, 1991-1993 (age - sex adjusted procedures per 1 ,000 beneficiartes) 





Vulnerable 














EXPECTED MFS PAYMENT CHANGE AREAS 






















Reduction 


^ 


























Increase 








^ 
























W' 






PoDulation 




1 






2 






3 






4 






S 






6 




ALL AREAS 






1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 




Shortaae Areas 














































All Shortage Combine 

Urban 

Rural 
Non-Shortage 


3.2' 
3.2 • 
0.0 ■ 
4.2 


3.1 • 
3.2' 
0.0' 
4.4 


3.2' 
3.3- 
1.2 • 
5.0" 


3.2 • 
3.1 • 
3.5" 
4.3 


3.6 • 
3.1 • 
4.9 
S.2 


4.5" 
4.0- 
5.7 » 
5.3 » 


2.5* 
2.4' 
3.5' 
4.4 


3.0* 
3.0' 
3.6 
4.4 


3.3- 
3.3' 
30* 
5.0 


3.0' 
2.5 • 
4.0 
4.1 


4.3 
3.8 
5.2 
4.6 


4.5" 
3.6" 
6.1 - 
4.6 


3.0' 
2.5' 
3.2 
3.8 


3.5 
3.0 • 
3.7 
4.2 


3.7- 
3.8" 
3.7" 
4.8' 


3.4" 
3.1 • 
3.6 
3.9 


3.6' 
2.8' 
4.0 
4.1 


4.4 ' 
3.0 • 
5.2 •" 
4.1 


2.9' 
2.5 • 
3.6' 
4.1 


3.7 • 
3.3' 
4.3 
4.5 


4.0 " 
3.5 " 
4,7" 
4,8" 




Poor Areas 














































All Poor Combined 

Urban 

Rural 
Non Poor 


2.3' 
2.3' 
1.5' 
4.3 


2.6" 
2.6" 
27 
4.5 


3.7- 
3.7" 
0.5' 
5.1 


32- 
3.2* 
2.5 ■ 
4.3 


3.0' 
3.1 • 
2.4' 
5.2 


3.6 • 
3.6' 
3.2 • 
5.4'' 


2.9' 
2.9- 
3.0' 
4.5 


3.1 • 
3.1 ■ 
3.1 • 
4.4 


3.1 • 
3.0' 
3.3 • 
5.1 


2.3 • 
2.0' 
4.0 
4.1 


3.2 ■ 
2.6' 
6.8' 
4.7 


3.3- 
30- 
5.4" 
4.7 


2.9' 
2.4' 
3.6 
3.8 


4.0 
3.4" 
4.9 
4.1 


3.9" 
3.0" 
5.4" 
4.8" 


2.7' 
2.4- 
2.9' 
4.0 


3.1 ■ 
2.4 • 
3,3 • 
4.2 


3.6" 
2.8" 
3.8 » 
4.1 


26" 
2.4 • 
3 3 ■ 
4.2 


3,2 • 
2,9' 
45 
45 


3,4 " 
3,1 " 
4 4 " 
48" 


o 
1 


Races 














































Black 
White 

Medicaid Ellalble 


1.8' 
4.4 


1.6- 
4.7 


2.4- 
5.1 


2.2* 
4.4 


2.2 ■ 
?.4 


2.7- 
5.5'' 


1.9* 
4.5 


2.5' 
4.5 


2 4 • 
5.2 


1.9' 
4.2 


2 2 • 
48 


2.5 • 

4.7 


2 1 • 
3.9 


2.4 • 

43 


3.3" 
4.8" 


1.4 • 
4.3 


1.7 ■ 
4.4 


1.5 • 
4.3 


19' 

43 


2,2 ■ 
4,7 


2,5 ■" 
49 » 




Yes 
No 


3.1 • 
4.4 


3.0' 
4.6 


3.2 • 
5.3" 


4.2 
4.2 


4.9 
5.2 


4.9 
5.3° 


35 
44 


3.6 

4.4 


3.8 ■ 

5.0 


2.5 • 
4,1 


36 

47 


3.4 
4.7 


2.7 • 

3.9 


2.8' 
4,3 


3.9" 
4.8" 


2.7* 
41 


3.6 

4,2 


2.7 • 
4.3 


3 1 • 
4.2 


36 • 
46 


3 7 " 
4,9" 




Disabled 














































Yes 
No 


6.2' 
4.0 


6.4' 
4.2 


6.8* 
4.8" 


5.9' 
4.1 


6.6- 
5.0 


7.6"' 
5.1 » 


5.6' 
4 1 


5.3' 
4.2 


60* 
4.8 


39 
4.0 


5.2 
4.5 


5.8'" 
4,4 


4.7- 
3.6 


5.5' 
4.0 


6.7- 
4.5" 


4.2 
3.9 


5,1 ■ 
4.0 


4.6 
4.0 


48- 
4.0 


54" 
4.3 


6,1 " 
4,6" 




Age 














































85+ Years 
Less than 85 


0.7* 
4.3 


1.3' 
4.4 


1.1 - 
5.1 » 


0.7- 
4.3 


0.9' 
5.2 


0.9' 
5.4" 


0.5 • 
4.4 


1.2 • 
4.4 


0.7 • 
5.0 


0.7* 
4.1 


0.8' 
4.7 


0.7" 
4.7 


0.5 • 
3.8 


0.8 • 
4.2 


1.0- 
4.9" 


0.5- 
4.0 


0.5 • 
4.2 


0.8" 
4.2 


n.6« 

4.1 


0.9' 
4.6 


08" 
4,9 " 




Aroa of Residence 


3.3' 
4.2 


2.3' 
4.4 


3.7- 
5.0" 


4.6 
4.2 


5.5 
5.1 


5.8'' 
5.2 " 


3.6 
4.4 


4.6 
4.2 


4.4 " 
5.0 


3.9 
4.0 


5.1 
4.5 


4.7 
4.6 


3.4 

4.1 


4.0 

4.3 


49" 
4.6 


4.0 
3.7 


4.3' 
3.6 


41 
4.0 


3.8 
42 


45 
44 






Rural 
Urban 


4,6 ' 
4,8 ■• 




Al 1 BENEFICIARIES 


4.2 


4.4 


5.0'' 


4.2 


5.1 


5.3 » 


4.3 


4.3 


4.9 


4.0 


4.6 


4.6 


3.8 


4.1 


4.7 " 


39 


4.1 


41 


40 


4.5 


4,7 » 



NOTES: 



Significantly diftef eiK from me companson group at the 0,06 level 
» SlgrtflcanHy dltlerent (rom 1991 to 1993 al the 0,05 level 

source: CHER analysis of Medicare Part A claims and denominator .e for a sample of benencianes 



niontand\finui;pnaf itifix ':\ I .iWc" 



TABLE C-22 

JOINT REPLACEMENTS BY EXPECTED MFS PAYMENT CHANGE AREAS AND VULNERABLE POPULATION GROUPS, 1991-1993 (age - sex adjusted procedures per 1,000 beneficiaries) 





Vulnerable 














EXPECTED MFS PAYMENT CHANGE AREAS 






















Reduction 


^ 
























^ 


Increase 








^ 
























W" 






Population 




1 






2 






3 






4 






5 






6 




ALL AREAS 






1991 


199? 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 




Shortaae Areas 














































All Shortage Combine 

Urban 

Rural 
Non-Shortage 


7.0 
7.0 
5.1 
6.5 


6.9 
6.9 
S.4 
6.8 


6.1 • 

6.2 • 
4.2 
7.3 


6.0' 
5.6 • 
7.2 
7.5 


6.3' 
5.6' 
8.7 • 
7.6 


6.9 ■» 
6.6 ■» 
7.7 
8.2 


4.7' 
4.1 ■ 
8.0' 
6.7 


4.9' 
4.5' 
7.6 
7.0 


4.7' 
4.2' 
7.7 
7.4 


6.7 
5.6 
8.5' 
69 


6.8 
59 
8.5 
7.3 


6.9 
5.2 ' 
9.6' 
8.0 


6.9 
5.6' 
7.5 
7.5 


8.6 
6.4' 
9.6 
8.6 


8.2 ' 

6.6 "> 
8.9 

8.7 » 


6.1 
5.7' 
6.4 
6.5 


6.4' 
6.2 • 
6.4' 
7.4 


6.2' 
5.7' 
6.5' 
7.7" 


6.2 ' 
5.1 • 
7.8 • 
7.0 


6.7 ' 
5.5 ' 
8.7 ' 
7.5 


6.6 '» 

5.2 • 
8.8 •" 
7.9° 




Poor Areas 














































All Poor Combined 

Urban 

Rural 
Non Poor 


5.8' 
5.8' 
2.9' 
6.6 


5.8' 
5.8 • 

4.4 
6.9 


5.3' 
5.3' 
3.9 • 
7.4 


4.9" 
4.7' 
6.2 • 

7.6 


5.1 • 
4.9* 
7.2 
7.6 


6.6" 
6.4 ■» 
8.3 » 
8.3 


4.6' 
4.5' 
5.2' 
6.8 


4.9' 
4.7' 
5.9' 

7.1 


4.8 ' 
4.5 ' 
6.4 •» 

7.5 


4.0' 
37' 
5.6' 
7.2 


4.9' 
4.6' 
6.3 
7.4 


4.7' 
4.3' 
6.5 ■» 
8.2 


5.5 • 
5.3' 
5.8' 
75 


5.8' 
5.5' 
6.2' 
8.7 


5.8' 
5.0' 
6.9 "> 
8.8'' 


5.0' 
4.1 ' 
5.3' 
6.6 


5.6' 
5.1 • 
5.7' 
7.6 


5.8 •» 
4.6* 
6.3" 
7.8" 


4.5' 
43' 
5.5' 
7.1 


5.1 • 
"8 • 
6.1 ' 
76 


5.1 '• 
4.7' 
6.5 "■ 
8.1 " 


1 
"■o 


Races 












































Black 
White 


5.3- 
6.9 


5.3" 
7.3 


6.4* 
7.8 


4.5' 
7.8 


5.6' 
7.8 


5.6 ■» 
8.5 


4.5' 
6.8 


4.6' 
7.3 


4.7' 
7.7 


4.3' 
7.2 


4.6' 
7.5 


4.8' 
8.3 


4.9' 
7.6 


53' 
8.8 


5.1 ' 
8.9" 


4.3' 
6.8 


4.9' 
7.7 


1.6' 
8.0" 


4.5 ■ 
7.2 


4.8 • 
7,7 


4 9 '" 
8.3 " 




Medicaid Ellalble 














































Yes 
No 


6.5 
6.5 


6.8 
6.8 


5.9' 
7.5" 


7.0 
7.5 


5.7' 
7.7 


6.5' 
8.4 


5.1 • 
6.8 


5.4' 
7.1 


6.1 
7.4 


5.6 
7.0 


5.4' 
7.4 


6.1 ' 
8.1 


6.4 ' 
7.6 


7.6 
8.7 


5.9' 
8.9'' 


5.2 • 
6.7 


5.9' 
7.7 


6.5'" 
7.9" 


5.8' 
7.1 


5.9' 
7.6 


6 2 • 
8.1 » 




Disabled 














































Yes 
No 


7.9- 
6.4 


7.9' 
6.7 


8.3' 
7.2 


9.0' 
7.3 


8.1 
7.5 


8.4 
8.2 


6.9 
6.6 


7.9 
6.8 


7.6 
7.2 


7.5 
6.8 


8.2 
7.1 


8.0 

7.9 


7.4 
7.5 


8.9 
8.6 


7.9 
8.7'' 


6.6 
6.5 


7.1 
7.4 


7.5" 
77" 


74- 
69 


8.1 ■ 
7.4 


7,9 " 
7.9 " 




Aae 














































85+ Years 
Less than 85 


5.9' 
6.6 


5.0- 
6.9 


5.4* 
7.3 


4.8 • 
7.5 


4.6' 
7.6 


4.5' 
8.3 


4.1 ' 
6.7 


4.2' 
7.0 


3.5 '» 
7.4 


3.7' 
7.0 


4.1 ' 
7.3 


3.4 • 
8.0 


4.0' 
7.5 


4.9' 
8.7 


4.8"' 
8.8" 


4.2 ' 
6.5 


4.8' 
7.5 


3.7'" 
7.8" 


4.1 • 
7.0 


4.4' 
7.5 


3 9 ' 
8.0" 




Area of Residence 














































Rural 
Urban 


4.0' 
6.6 


5.8' 
6.9 


6.0 * 
7.3 


8.8' 

7.3 


8.6' 
7.4 


9.0 
8.1 


7.2 
6.5 


8.0' 
6.7 


8.4 "> 
7.0 


8.1 
6.6 


8.5 
6.9 


86 

7.7 


8.3' 
67 


8.8 
8.4 


9.3 
8.0" 


6.2 • 
7.1 


7.4 
7.4 


7.:- •» 

8.4 " 


7.7' 
6.7 


8.3 • 
7.1 


8.5 "" 
7 6 " 




ALL BENEFICIARIES 


6.5 


6.8 


7.3 


7.5 


7.5 


8.2 


66 


6.9 


7.3 


6.9 


7.2 


7.9 


7.4 


8.6 


8.6" 


6.5 


7.4 


7.7" 


6.9 


74 


79' 



NOTES: 

• Significantly ditterent from the comparison group at the 06 level 
» Signincantly different from 1991 to 1993 at the 05 level, 

SOURCE CHER analysis of Medicare Part A claims and denominator file tor a sample of beneficlanes 



rTiontana\tinalrpt\appri<-.,\ldii;< 



TABLE C-23 

AR THROSCOPIES BY EXPECTED MFS PAYMENT CHANGE AREAS AND VULNERABLE POPULATION GROUPS, 1991-1993 (age - sex adjusted procedures per 1 ,000 beneficiaries) 





Vulnerable 
PoDulatlon 














EXPECTED MFS PAYMENT CHANGE AREAS 














ALL ARE/ 






Reducttor 

1 


^ 


























w 


Increase 
6 








■^-^ 




2 






3 






4 






5 




-W' 


kS 




1991 


1992 


.1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 


1991 


1992 


1993 




Shortaqe Areas 














































All Shortage Combined 

Urban 

Rural 
Non-Shortage 


5.4' 
5.5' 
0.0 ■ 
7.6 


8.4 

8.3 

14.8 

8.2 


8.5" 
8.6' 
0.0' 
8.3 


4.3 
3.5- 
6.7- 
4.8 


5.3' 
4.9' 
6.6 
6.7 


4.2 • 
3.4' 
6.7 
5.8 


2.9 
2.6" 
4.5 
3.9 


3.5 
3.3 
5.0 
4.4 


3.4' 
3.2 • 
4.1 
5.1 


2.6 
2.5 
2.8 
3.2 


33 
2.8 
4.1 
4.0 


4.1 >■ 
3.3 
5.5" 
4.1 


2.5 
1.5' 
3.0 
2.8 


3.6 
2.6- 
4.1 
4.0 


3.1 
2.0" 
3.5 
3.7" 


2.6 
3.3 
2.2' 
3.3 


3.6 
4.6' 
30 
3.6 


3.4' 
4.8" 
2.7 ' 
3.6 


2.8' 
2.6 » 
3.2 ' 
3.7 


3,7 ■ 
3,4 ' 
4.2 
45 


3,7 ».. 

3.3 ,u 

4.4 I 
4.6, 




Poor Areas 














































All Poor Combined 

Urban 

Rural 
Non Poor 


4.4' 
4.5' 
3.1 • 
7.7 


3.9' 
3.9' 
3.5' 
8.5 


6.2" 
6.2" 
5.3 
8.5 


2.3' 
2.3' 
2.4' 
4.9 


3.1 • 
3.0- 

4.2 • 
6.8 


3.0" 
2.9' 
3.9" 
5.8 


2.2" 
2.1 ■ 
2.9' 
4.1 


2.3 • 
2.1 • 
3.0' 
4.6 


2.7 • 
2.7' 
2.5' 
5.2 


2.1 • 
2.0' 
2.7 
3.2 


2.2 ■ 
2.0' 
3.1 
4.1 


2,7' 
2.5" 
3.8' 
4.2 


1.9' 
1.3' 
2.8 
2.9 


2.7' 
2.3' 
3.1 ' 
4.0 


3.1 " 
1.9* 
5.0 
3.7' 


2.1 ' 
2.0" 
2.1 ■ 
3.4 


28' 
2.3' 
3.0 
3.6 


3.2 ' 
2.2 ' 
3.5' 
3.7 


2.2 ' 
2.1 ' 
2.6' 
3.7 


2.4 ■ 
2.3 ' 
3 1 ' 
46 


2 9 „i 
2 7 « 
37 « 
4.6 .. 




Races 












































o 


Black 
White 


2.5' 
8.3 


3.8' 
8.9 


4.9" 
85 


1.5' 
5.2 


2.1 ■ 
7.1 


2.0" 
6.1 


1.5' 
4.2 


2.2' 
4.7 


2.1 ' 
5.3 


1.8- 
3.3 


2.5 • 
4 1 


19* 
4.3 


1.2 • 
2.9 


2.0' 
4.1 


1.6" 
3.9° 


1.1 • 
3.6 


1.7 ' 
3.8 


1.5' 
3.9 


le- 
ss 


2-2 - 
4.7 


1.9 .: 

4.8 :. 




Medicaid Ellalble 














































Yes 
No 


4.6- 
8.0 


4.7' 
8.7 


6.7" 
8.6 


3.8 
4.9 


4.3' 
6.9 


3.5 • 
5.9 


2.5' 
4.1 


2.8- 
4.6 


3.3 • 
5.2 


2,1 
32 


28 
4.0 


2.6' 
4.2 


1 9« 
2.9 


1.8' 
4.2 


2.8 
3.8' 


1.9" 
3.5 


2.1 ' 
38 


2.4 • 
38 


2,5" 
37 


28 ' 
4,7 


3 1 „ 
4.7 ,. 




Disabled 














































Yes 
No 


7.2 
7.6 


8.0 
8.2 


8.9 
8.3 


6.0" 
4.7 


6.6 
6.7 


6.5 
5.6 


3.9 
3.9 


3.8 
4.4 


5.5- 
4.9 


3.9 
3.0 


3.8 
3.9 


3.8 

4.1 


3.0 
2.8 


3.5 
40 


3.9'^ 
3.7 


3.4 
3.3 


3.5 
3.6 


4 2 ■ 
3.5 


4,0 
3,6 


4,1 
45 


47 
45 




Age 














































85+ Years 
Less than 85 


1.3' 
7.7 


1.9' 
8.4 


1.0" 
8.6 


0.7' 
4.9 


1.8' 
6.8 


0.7 ■ 
5.8 


0.6' 
4.0 


1.3' 
4.5 


0.8- 
5.1 


0.5' 
3.2 


0.6' 
4.0 


1.4" 
4.2 


0.4' 
2.9 


0.6' 
4.0 


0.7" 
3.8' 


0.6" 
3.4 


0.4- 
3.7 


0.6 ' 
3.7 


0.6 < 
37 


0,9 ' 
46 


1 .■, 

4ti 




Area of Residence 














































Rural 
Urban 


2.4' 
7.7 


2.4 • 
8.4 


3.4" 
8.5 


5.2 
4.7 


6.1 
6.7 


5.9 
5.7 


3.0 
4.1 


3.8 
4.5 


3.6' 
5.2 


3.3 
3.1 


4.0 
3.9 


4.6' 
3.9 


3.2 
2.5 


3.9 
4.0 


36 
3.8' 


2.9' 
4.2 


3.2 ' 
4.4 


3,4 
4.2 


3.3 
38 


3 9 ' 
47 


4 ,1 
47 . 




ALL BENEFICIARIES 


7.5 


8.2 


8.4 


4.8 


6.7 


5.7 


3.9 


4.4 


5.0 


3.1 


3.9 


4.1 


2.8 


3.9 


3.7' 


3.3 


3.6 


3.6 


3.6 


45 


45 



NOTES: 



' Slgrlflcontty dit(e.ent from the companson group at Ifie 05 levet 
' SlgniflcanHy different from 1991 to 1993 «t the 0,0S level 

SOURCE; CHER analysis of Medicare Part B dalnns and denofrtnator file for a sample of beneficiaries 



riiorittjna\finiilrpt\tippfn f\Icii.|t . * 



ens LIBRflRV 




3 amS DDD13D17 5 



^ •